Published: July 23, 2025
Migraine affects 37 million men, women and children in the United States and ranks among the top 10 most disabling medical conditions, according to the World Health Organization. More than 90% of patients report that migraine interferes with education, career and social activities – making early recognition and treatment in pediatric populations particularly crucial.
Paul H. Gong, M.D., pediatric neurologist and headache medicine specialist with Norton Children’s Neuroscience Institute, affiliated with the UofL School of Medicine, presented this information at “Updates in Pediatrics: Migraines in Children and Teens,” a recent continuing medical education opportunity.
The International Classification of Headache Disorders (ICHD-3) provides standardized criteria for migraine diagnosis, but pediatric patients present unique characteristics that clinicians must recognize.
For migraine without aura, patients need at least five attacks lasting four to 72 hours (untreated) with two of these qualities: unilateral location, pulsating quality, moderate-to-severe pain or aggravation by routine activity. They also must have nausea/vomiting or both photophobia and phonophobia.
However, children differ significantly from adults. Pediatric migraine headaches are more often bilateral, particularly in the bifrontal or bitemporal regions. Occipital location, while sometimes considered a red flag, occurs commonly in pediatric migraine. Attack duration can be as short as two hours in children, and photophobia/phonophobia may need to be inferred from behavior rather than verbal reports.
Chronic migraine – defined as 15 or more headache days per month for three months – affects 1% to 2% of adolescents, with socioeconomically disadvantaged patients at higher risk.
Several migraine variants require recognition. Migraine with brainstem aura (formerly basilar-type migraine) includes symptoms like dysarthria, vertigo, tinnitus and altered consciousness without motor weakness. Hemiplegic migraine involves motor weakness plus other aura symptoms, often with familial patterns showing autosomal dominant inheritance.
Episodic syndromes associated with migraine frequently precede typical migraine development. Cyclic vomiting syndrome involves five attacks of intense nausea and vomiting in stereotypical, predictable patterns. Abdominal migraine presents as poorly localized midline abdominal pain with associated symptoms. Benign paroxysmal vertigo causes vertigo attacks with fearful behavior being a key diagnostic feature.
Current understanding has shifted from the outdated vascular theory to recognizing migraine as a disorder of neuronal hyperexcitability. Genetic predisposition creates susceptibility to neuronal triggering, activating the trigeminovascular system and multiple brain regions, including the hypothalamus and thalamus. This explains why migraine is a complex neurologic disorder, not simply “bad headaches.”
While neuroimaging isn’t necessary for patients meeting migraine criteria with normal neurologic exams, certain red flags warrant investigation: thunderclap headache, symptoms in children under 3, prolonged aura lasting more than one hour, early morning intractable vomiting and abnormal neurologic findings.
Occipital headache alone doesn’t require imaging if other concerning features are absent and neurologic exam is normal.
The PedMIDAS (Pediatric Migraine Disability Assessment) score helps quantify disability by measuring missed school days and impaired activities, providing objective treatment targets beyond frequency reduction.
Acute treatment success depends on early, aggressive intervention with appropriate dosing. Nonsteroidal anti-inflammatory drugs (NSAIDs) remain first-line therapy, with ibuprofen dosed at 800 to 1,000 milligrams maximum and naproxen at 750 to 1,000 milligrams in pediatric patients. Higher doses prove more effective and are generally well tolerated.
Triptans serve as second-line therapy for moderate-to-severe attacks. Rizatriptan is Food and Drug Administration-approved for ages 6 and up and comes in melt formulation, while sumatriptan and others are approved for ages 12 and up. Combination therapy with NSAIDs and triptans shows superior efficacy for severe attacks.
Medication overuse headache develops with acute medication use more than three days weekly, requiring complete washout for resolution.
Diagnostic considerations:
Red flags requiring investigation:
Treatment principles:
Contraindications for triptans: