Migraines and childhood


Migraines in children

Migraines in children

Little is known about the prevalence of migraine in children and school-age compared to adulthood. In a Scandinavian study conducted in the early 1960s, the prevalence of migraine was reported to be 2.5% in 7- to 9-year-old children, 4.6% in 10- to 12-year-olds, and 4.6% in 13- to 15-year-olds -year-olds 5.3%. These data have been essentially confirmed by recent studies in other countries. There is no further information about the occurrence of migraines in preschool children, although migraine attacks can also occur in this early childhood.

In earlier centuries, little thought was given to headaches in children The prevailing opinion was that headaches hardly play a role in small children and school children. At the beginning of the 19th century, an infant was first described who suffered from cyclic vomiting at two weeks of age and was later diagnosed with migraine. It was only in the second half of the 20th century that papers on headaches in small children aged one and over were published. As a rule, it has been shown that headaches begin in the 2nd and 3rd year of life. A study of London children found that 4% of mothers of 3-year-old children reported that headaches were currently a problem for their children.

Occurrence of headaches in children

– A history of headaches is reported in 8% of children.

– Recurrent headaches are present in 3% of children.

– It is also known from studies in other countries that between 3% and 4% of children by the age of three already suffer from headaches.

– A large Finnish study of over 5,000 children showed that by the age of 5, 19.5% of children had already suffered from severe headaches.

There was a high headache frequency in 0.2%, a medium headache frequency in 0.5%, a low headache frequency in 4.3% and occasional headaches in 14.5%. Interestingly, this study also revealed a number of predictors for the occurrence of childhood headaches.

Low housing standards, low economic status of the family, full-day kindergarten placement and a large number of leisure activities are associated with a greater risk of headaches in childhood.

The incidence of abdominal pain was increased nine-fold in children who suffered from occasional headaches and fourteen-fold in those who suffered from moderate frequency of headaches.

It is known from Finnish studies that as start school . Already in the first school year, 39% of children reported suffering from headaches. 1.4% of children in their first year of school met the criteria for migraine .

These results were collected in a large study in Sweden (Uppsala) in 1955. While in 1955, when the first study was carried out, a migraine prevalence of 1.4% was shown, a comparable study in 1976 showed a migraine prevalence of 3.2 and finally in 1994 a migraine prevalence of 5.7%. in children aged 7 years.

These figures indicate that the incidence of migraines has obviously risen sharply in school children over the decades.

also an increasing prevalence of headaches in school age as age increases . In children between the ages of 7 and 15 years, there is a headache prevalence of 58.7%. 3.9% of children in this age group meet the criteria for migraine. Very similar data can be found in studies from other countries.

A German study carried out in 1994 by Pothmann's working group on over 5,000 school children showed that over 52% of school children suffer from tension-type headaches and 12% from migraines (Pothmann et al. 1994). By the time they start school, over 10% of children suffer from headaches of significant distress. Over the course of different school years, this frequency increases to over 90% of children. 49% suffered from tension-type headache, 6.8% from migraine with aura and 4.5% from migraine without aura.

A Finnish study shows very similar figures: among Finnish schoolchildren, 71% of girls and 65% of boys had severe headaches at the age of 14. 6.7% of boys and 13.8% of girls met the criteria for migraine.

Overall, there was a migraine prevalence of 10.2% in this sample at the age of 14.

While children with headaches are the minority when they start school, the picture changes fundamentally for 14-year-olds. Here, the children for whom headaches are not a problem represent the outlier group. As they continue into their teens the picture remains constant. About a third of adolescents have no problems with headaches, half of adolescents suffer from occasional headaches, and the rest have frequent headache problems.

changes in the gender distribution during school age . During the first school year there is a slight predominance of headache prevalence among boys. During the 14th year of life, however, the picture is reversed and there is a slight predominance of headache prevalence among girls. This predominance then increases continuously until the age of 20, and around twice as many girls as boys report suffering from headaches with significant disability by the age of 20.

In addition to this change in relative prevalence, there are also differences in progression between and within gender groups . If the migraine has already occurred before the age of 7, the affected boys are more likely to have a reduction in migraine attacks. 22% of boys experience partial or complete remission of migraine, while only 9% of girls in whom migraine first appeared before the age of 7 have corresponding remission. However, the situation looks different when looking at children in whom migraines first occurred between the ages of 8 and 14. 51% of boys and 62% of girls in this group still have clinically manifest migraines in later life.

Headaches and possible effects of drug abuse

– According to studies carried out by the “Gläserne Schule” campaign in Schleswig-Holstein (Institute for Addiction Prevention and Applied Psychology, Bremen) in 1995, headaches are one of the main health problems of school-age children.

– A representative survey of schools found that, depending on the type of school, between 20% and 40% of students reported headaches as an important and persistent health problem. Shockingly, this survey also revealed clear evidence that headaches are a major reason for the development of addictive behavior and drug abuse.

– Due to the disabling pressure that the headaches cause, the children can become receptive to trying drugs and try to use them to improve their well-being.

– Special knowledge about headache treatment and headache prevention seems to be of great importance in preventing drug addiction in children!

The question of whether headaches have increased in our century was not resolved until recently. In Finland in 1992, a study on migraine prevalence was repeated in almost every detail as it had been carried out in the same region in 1974. Seven-year-old schoolchildren were examined.

It turned out that in 1992 51.5% of children had already suffered from headaches, while in 1974 only 14.6% of children reported a corresponding headache problem . The existence of frequent headaches, ie at least one or more attacks per month, was answered “yes” by 11.7% of children in 1992, while a corresponding frequency of headaches was reported by only 4.7% of children in 1974 . A gender-specific comparison shows that the increase in headaches is particularly noticeable in boys

The figures show dramatic increases in the prevalence of headaches in children. The authors of the Finnish study assume that an unstable social environment, frequent moves, lack of self-determination in the social community, feelings of insecurity in the family and at school and the lack of leadership are to be blamed for this increase in headache prevalence.

The conclusion that must be drawn from these data is that pedagogical measures as well as content requirements in school lessons need to be reconsidered. Just as it was recognized at the beginning of the 20th century that in order to maintain dental health, schools needed to teach how to brush teeth and eat healthily, just as at the same time increased attention was paid to physical education in order to maintain physical health, so too today Particular attention should be paid to maintaining the health of the nervous system in schools.

This includes at least early learning of relaxation training , which should be practiced regularly, techniques for dealing with stress , information on how to organize a regular daily routine , occupational psychology instruction , health education regarding adequate nutrition and sleep hygiene . These measures would be easy to implement. Due to the known pathophysiology of headaches, it can be expected that this would enable a positive intervention in the steady increase in headache prevalence in school-age children.

Diagnostic criteria

Early childhood prevalence studies used Vahlquist's 1955 diagnostic criteria (Vahlquist 1955). Comparative studies using the Vahlquist criteria set and the International Headache Society criteria for the diagnosis of migraine show that 70% of headache patients meet both the International Headache Society criteria and the Vahlquist criteria, 80% meet the International Headache Society criteria and 90% of those affected meet the Vahlquist criteria. This shows that the agreement between the two definition systems is relatively high. However, the old Vahlquist definition has greater sensitivity for migraines.

In the International Headache Society classification, headache attacks in children lasting less than four hours be classified as migraine attacks.

From recent studies it is known that the duration of the attack has little influence on the effectiveness of the treatment of migraine attacks , meaning that the same therapeutic effects can be achieved regardless of whether the attack lasts spontaneously for four or two hours. In this respect, an exact determination of the duration of attacks in children seems of less therapeutic relevance . Whether this is the same in adults has not yet been investigated.

Determining the characteristics of headaches in children is more difficult than in adults. This is primarily due to the fact that there accurately express symptoms in children than in adults. Children have also only suffered from a small, manageable number of attacks and are not yet able to precisely state characteristic course with typical expression of the characteristics . two to 48 hours in children if it is untreated or unsuccessfully treated . However, young children also experience attacks that last less than two hours.

Since the required number of migraine attacks, namely more than five, is of course not yet met, especially with new migraine illness, an initial diagnosis in childhood can often only be made as a diagnosis of a migraine -like disorder Only the further course with the typical occurrence of further attacks then meets the required criterion.

Since children often do not have the ability to express their migraine attacks clearly in language, it is important to pay particular attention to the diagnosis when it comes to headache attacks .

What is crucial is the question asked either of the child or of the parents,

whether there is complete freedom from headaches between the individual attacks and whether the children are otherwise healthy ,

i.e. have neither psychological nor physical problems. In connection with a real general and neurological finding, there is a high probability that these are actually migraine attacks

difficult to differentiate between an episodic tension-type headache with this approach . , this is rare , but on the other hand, the therapeutic approach for both types of headache in childhood is still very similar.

Peculiarities of clinical features

The same diagnostic criteria apply to migraine in childhood as in adulthood, but with the aforementioned exception of the shorter duration of the attacks. In addition to the accompanying disorders that are prominent in adults, there are additional accompanying disorders in children that can also be of diagnostic importance:

– During the attack, the affected children experience tachycardia, paleness or reddening of the skin, changes in well-being, thirst, appetite , urination or tiredness . They may a high temperature , may yawn or restless , and may also report pain in other areas of the body , particularly in the abdominal area. The focus is also on disorders of the digestive organs such as loss of appetite, nausea, vomiting, diarrhea and increased defensive tension of the abdominal walls.

Neurological aura symptoms can be just as pronounced as in adults and can occur in a wide variety. visual disorders are particularly prominent. In the literature, the frequency of visual aura in migraine attacks in children is reported to be between 9% and 50%. Other common aura symptoms include paresis , sensory disorders and speech disorders .

Precise types of migraines in childhood

, all forms of migraine can be present in childhood , but some migraine aura processes appear in particular types.

In addition to the visual aura, basilar migraine particularly common expression of migraine aura in childhood . In children, neurological disorders occur in the form of bilateral visual field disorders, loss of tone, nystagmus , diplopia, dysarthria and impaired consciousness . Although the attacks usually occur at long intervals, they can last 24 to 72 hours. Particularly in the case of such accompanying neurological disorders, a careful examination by a neurologist necessary in childhood.

The following are particularly the differential diagnosis : a tumor in the posterior cranial fossa , medication side effects (e.g. antiemetics), mitochondrial disorders and metabolic diseases .

However, migraine aurora through changes in affect and cognition .

The so-called “Alice in Wonderland syndrome with acute states of confusion is particularly well known.

Even with such disorders, structural lesions carefully ruled out.

Familial hemiplegic migraine is a particularly characteristic form of migraine aura in childhood. Here too, the paroxysmal course is diagnostically groundbreaking. This form of migraine occurs extremely rarely.

Migraine equivalents

Migraine equivalents are defined by the occurrence of vegetative or visceral disturbances of migraine , but the headache features are absent. When focal neurological disorders occur that meet the criteria for migraine aura, but no headache phase is present, it is not referred to as a migraine equivalent, but rather as a migraine aura without headache . The term migraine equivalent refers solely to the visceral and vegetative accompanying features of migraine without aura.

Typically the symptoms consist of nausea , vomiting , malaise, bowel movements or other unspecific symptoms . If such disorders periodically , such as cyclic vomiting, the disorders are particularly often associated with migraine attacks. However, empirical data on the connection between these equivalents of a migraine attack and the actual migraine are very sparse. As a rule, this is only a diagnosis of exclusion or embarrassment if all other examinations have not been able to uncover a specific cause. In the case of corresponding disorders, particular care should be taken to look for gastrointestinal diseases, metabolic disorders, epileptic syndromes, brain tumors, mitochondrial disorders and, in particular, mental illnesses .

Possible precursor syndromes in childhood

Benign paroxysmal torticollis in childhood

Repeated episodes of torticollis can occur even in infancy . The movement disorders remit later in infancy , which is why the addition “benign” is justified. The disorder is very rare. Only in a small proportion of affected children are the torticollis episodes later replaced by migraine attacks. It is not clear whether there is a direct connection between migraines and this movement disorder. The pathophysiology of torticollis episodes in infancy is also unclear. It is conceivable that these aura phases as part of migraine auras. However, no definitive statement is currently possible.

Benign paroxysmal dizziness in childhood

In childhood , short-term, severe episodes of dizziness lasting less than half an hour occur, which are often accompanied facial paleness , nausea and vomiting The syndrome occurs significantly more frequently than benign paroxysmal torticollis in childhood. As a rule, this disorder remits by the time the child starts school . The pathophysiology of this disorder is still unclear; the connection with migraines can be assumed due to the paroxysmal nature and the accompanying disorders.

Motion sickness

An increased susceptibility to motion sickness in children is also associated with migraines. Empirical data for this connection are still missing. Under no circumstances can a diagnosis of migraine be based solely on a tendency to motion sickness. The activities associated with traveling can not only lead to motion sickness, but can also trigger migraine attacks.

Selection of additional examinations

The indication for additional examinations such as EEG or imaging procedures is similar to that in adulthood . Since, due to age, there is often only short history of the course of the headache, the situation will often arise in childhood where a headache diagnosis has to be made for the first time and the paroxysmal course of the headache disorder is not yet documented due to the short time it has been present.

For this reason, special care must be taken to rule out the presence of headache due to a structural lesion in children. This is particularly true for a cranial mass. Special attention is necessary for very young children under the age of 6. Up to this age, primary headaches are significantly less prevalent than later in life, and the likelihood of headaches in connection with structural lesions is therefore significantly greater in preschool age than in later life.

For this reason the rule be observed that an imaging procedure should be used in children under the age of 7 when a headache occurs for the first time. Due to the lack of radiation exposure, an MRI should preferably be ordered. In any case, an imaging procedure should be carried out if the children also have growth delays, visual disturbances, changes in thirst or appetite, affective or cognitive symptoms or motor problems.

The prevalence of primary headache disorders increases rapidly in school age. For this reason, carrying out imaging procedures only if there are deviations in the general and neurological findings . This is particularly true if the headache disorder has been present in attacks for more than six months.

Indications for the use of imaging procedures for headaches in children

to the implementation of imaging procedures in the diagnosis of headaches in children as in adults. The prerequisite is a detailed anamnesis including an exact recording of the headache characteristics of the existing headache disorders.

precise description of school performance should also be collected. While preschool children with a short history of headaches should have an imaging procedure carried out regularly , it is only recommended for school children if there are pathological deviations in the general or neurological findings. The indication for the imaging procedure is also based on the following features:

Change in the course of the headache with new onset of neurological disorders, increase in headache frequency, increase in headache intensity, increase in headache duration.

–       Lack of response of the headache attacks to the therapy initiated.

–       Retardation of growth, increase in head circumference above the age norm.

Change in affective and cognitive functions.

Reduced performance at school, sensorimotor disorders.


Epilepsy and migraines

Epilepsy and migraines occur in attacks and the connection between these two disease entities has been discussed very intensively in the literature in the past.

Of particular importance is that etiological conditions for headaches and epilepsy , such as brain tumors, vascular malformations, etc., can be identical. Parallels were also drawn with regard to therapy and, for example, anticonvulsants were also used to prevent migraines.

For a number of disorders, both types of migraine and epilepsy be considered in the differential diagnosis. As already explained above, these include cyclic vomiting , recurrent, paroxysmal abdominal pain , dizziness , and mental disorders that can occur both as part of a migraine attack and in complex focal attacks. EEG plays a special role in diagnostics diagnostically groundbreaking in connection with epileptiform discharges and clinical phenomena .

– Epileptic seizures can be distinguished from migraines from a clinical perspective, particularly by their temporal progression. Epileptic seizures are characterized by a sudden onset, a short duration in the range of minutes or even shorter, changes in consciousness before and after the event and a clearly defined end of the seizure.

– Migraine, on the other hand, is characterized by a slow onset with gradual spread of symptoms, a longer period of time in the range of hours and a gradual resolution.

Another connection between migraine and epilepsy is the induction of postictal headaches following an epileptic seizure . Epileptic seizures can trigger migraine attacks and episodic tension -type headaches

clear connections between the prevalence of various epileptic seizures and migraines . Two thirds of patients who have of Rolandic epilepsy are also have headaches similar to migraines . benign focal epileptiform discharges also said to occur in around 9% of children with migraines. The characteristic encephalographic features of these disorders are found in just under 2% of the normal population.

Syncopal seizures, orthostatic dysregulation

Orthostatic dysregulation and even syncope can occur as part of migraine attacks. It is known from systematic studies that orthostatic dysregulation can occur three times more frequently in migraine patients

However, the etiology and pathogenesis of these disorders have not yet been clarified or systematically analyzed.

Cerebral infarction and migraines

very sparse information about the frequency of the connection between a cerebral infarction and migraines in childhood . There is no doubt that migraine attacks can occur at any age.

In a Swiss cohort study in which 600 children in Bern were examined over a longer period of time, it was found that three of the affected children had a cerebral infarction between the ages of four and 14 years. This means that, based on these data, the risk of having migraine attack in childhood must be stated 0.5%

However, detailed investigations are not yet available. a good tendency to recover compared to adulthood and that long-term failures are either very weak or non-existent . The greatest likelihood of cerebral ischemia during a migraine attack is in the area of ​​the posterior cerebral artery.

The so-called MELAS syndrome must be considered in the differential diagnosis. This is metabolic encephalopathy associated with lactic acidosis and stroke-like episodes.

The MELAS syndrome is characterized by migraine-like headache episodes , which are characterized by a wide variety of accompanying disorders.

bilateral neurological disorders appear , which become apparent stroke-like episodes and epileptic seizures The diagnosis is made primarily by the clinical course . In addition, the CCT or MRI shows bilateral occipital necrosis and edema , sometimes with bleeding, and in particular the eponymous lactic and pyruvate acidosis in the cerebrospinal fluid. ragged-red fibers can be found in the muscle biopsy .

Of further differential diagnostic importance are Moya-Moya disease , alternating hemiplegia in childhood , arteriovenous malformations , cerebral masses and inflammatory diseases , especially isolated cerebral arteritis.

A migraine infarction does not be associated with signs of a cerebral infarction on imaging (CCT or MRI). The decisive factor for the diagnosis is the permanent clinical deficits , but not a corresponding correlate in the imaging procedures.

The question of whether migraine itself increases the risk of a stroke has not yet been conclusively answered. Studies on adults show evidence that the risk of stroke is increased by a factor of 1-3 due to migraines.

Differential diagnosis of headaches in children

Tension-type headache

In children under the age of 10, tension-type headaches are rarely present, but from the age of 15 onwards, they are the most common cause of headaches . Tension-type headaches typically occur in the entire head , but particularly in the neck area. Chronic tension-type headache in children is characterized by modulation of pain intensity , and headache-free days cannot be reliably defined by low headache intensity.

Nausea, vomiting, accompanying vegetative disorders such as facial pallor make it relatively easy to distinguish migraines from tension-type headaches. For diagnosis it is necessary to check exactly the criteria of the classification of the International Headache Society. In addition, a careful neurological and general examination must be performed.

The etiological factors for tension -type headache cannot always be identified. Psychological disorders rarely manifest themselves in the form of tension-type headaches under the age of 10 .

When the temporomandibular joint is disturbed, pain radiates to the ipsilateral ear . During the dental examination a malocclusion , bruxism or other parafunctions or even excessive chewing of gum turn out to be the cause.

If you have a temporomandibular joint disorder hot compresses , physical therapy in the form of jaw exercises with conscious, slow opening and closing of the mouth, and analgesic therapy can be helpful.

If school-age children have tension-type headaches , therapy should primarily consist non-drug measures This includes, in particular, learning relaxation training and checking stress factors in the family and school areas.

Headache in structural lesions

Headaches associated with structural lesions are also the exception in childhood . Recurrent or persistent headaches, apart from acute processes such as infections, are caused by structural lesions in far less than 2% of children However, the clinical distinction between primary and secondary headaches is difficult in children because exact clinical features are usually not available.

Headaches with structural lesions are also often manifested by the clinical features of the primary forms of headache, particularly migraine and tension-type headache.

Therefore, in children with headaches, great attention be paid when assessing the symptoms of the headache, but also during the general and neurological examination. Headaches due to structural lesions in childhood can have just as many different causes as in adults. In this respect, the entire range of differential diagnostics be considered. The most common secondary headache disorders are described below.

Cranial masses

The development of a cranial mass is usually manifested by clinical symptoms that continually increase over time.

Initially, intracranial masses may present with a phase of gradually increasing headaches lasting two to four months. More than 95% of affected patients have additional neurological disorders that can be clinically recognized by an experienced neurological examination.

If there are no such neurological disorders, but if suspicions in the form of psychological or cognitive abnormalities, performance deficits at school or developmental disorders , clinical check-ups should be carried out closely at weekly intervals . Increased intracranial pressure typically presents with a headache when waking up after an afternoon nap. The occurrence of epileptic seizures associated with headaches is a serious indication of the development of a brain tumor and must be clarified diagnostically through a careful neuropediatric examination.

Vascular malformations

Headaches with a fixed lateral location raise the suspicion of a vascular lesion , particularly an arteriovenous malformation (AVM). Symptoms of such lesions, apart from headaches, include bleeding with neurological deficits . Epileptic seizures can also be typical manifestations of corresponding malformations. Moya -Moya disease can be associated with bilateral headaches and alternating hemiplegia.


The sign of hydrocephalus in children is the enlargement of the head . Hydrocephalus occlusus can occur, for example, in Arnold-Chiari malformation and other causes of aqueduct occlusion. The symptoms develop relatively quickly and spontaneous improvements cannot be observed. In infancy and childhood, intracranial hemorrhages, meningitis and other inflammatory diseases are common causes of hydrocephalus communicating .

The clinical features manifest themselves in the form of an increase in head circumference and increased fontanelle tension. As the disease progresses, pronounced vein markings, the sunset phenomenon and widening of the cranial sutures become apparent. In severe cases, additional neurological deficits such as eye muscle paresis, optic disc congestion, optic atrophy, para- or tertraspasticity and cerebral seizures occur.

Pseudotumor cerebri

A common cause of symptomatic headaches in childhood is benign intracranial pressure increase . Pathophysiologically, the disorder is manifested by cerebral edema , which is probably caused obstruction of venous drainage In childhood, the disease is often associated with otitis , head trauma or corticosteroid withdrawal.

headache characteristics are similar to those of an intracranial mass . The headache condition can continually increase over time . However, focal and general neurological disorders are absent. Ophthalmoscopy reveals papilledema , examination of the cerebrospinal fluid reveals increased CSF pressure , and the headache can be improved by taking CSF with a pressure reduction .

Traumatic brain injury

Minor traumatic brain injuries can trigger migraine attacks in children and adults. Footballer's migraine is particularly well known, in which migraine attacks can occur when hitting the ball. In children, such events can also manifest themselves as vomiting or dizziness . The entire manifestations of migraine attacks can develop.

In severe traumatic brain injuries impaired consciousness and serious neurological deficits are the main symptoms due to intracranial hemorrhage or malignant cerebral edema . Headache manifests itself as a secondary symptom. In the case of a subdural hematoma or a hygroma headache can prominent symptom that requires further diagnostics. Traumatic brain trauma can result in post-traumatic headaches.

In childhood, post-traumatic disorders particularly characterized by affective and cognitive changes .

Acute inflammatory processes

Acute rhinosinusitis can cause headaches in children. On the one hand, the inflammation can directly responsible for the headache syndrome, but it can also as trigger for migraine attacks in sensitive patients. After the process subsides and flares up again, it is possible that recurring headaches also be explained by sinusitis.

A feature of headaches in an acute sinus process is localization in the area of ​​​​the forehead, eyes and above the sinuses. Accompanying disorders include obstruction of nasal breathing, tenderness to percussion over the paranasal sinuses, swelling of the face above the sinuses and an increase in the intensity of pain when the head is bent forward due to movement of the secretion level in the paranasal sinuses.

Contrary to popular belief, headaches are not related to chronic sinus infections Sinus operations or other manipulations in the nose area generally do not lead to relief from headache symptoms in these chronic processes. In the case of persistent headaches a specific cause be identified particularly carefully This is often due to medication overuse or a chronic tension- type headache .

Other acute inflammatory processes , in particular viral inflammation or mononucleosis also often the cause of acute headaches in children. The typical accompanying disorders of primary headache disorders such as migraines are absent in these disorders.

In meningitis or encephalitis, headaches can be an early and significant symptom. The neurological examination reveals characteristic abnormalities that prompt further diagnosis. Increases in temperature and pleocytosis in the cerebrospinal fluid as well as changes in the blood count demonstrate the inflammatory genesis.

arteritis and collagen must also be considered as the cause of permanent or episodic headaches.

Behavioral medical therapy measures

Behavioral measures are at the forefront of the treatment of migraines in children .

In principle, the same rules apply here as in adulthood. The search for trigger factors is even more difficult in childhood than in adulthood, as children often cannot directly state which conditions can trigger migraines. Another crucial difference is that the information filtered information from the parents , so it can be very difficult to adequately find out the child's individual assessment of stress factors via the parents. Advice on lifestyle , nutrition, leisure and work habits are also particularly important.

Dietary measures such as cutting out cheese, chocolate, citrus fruits or dairy products rarely lead to success. The data on the connection between such factors and the triggering of migraine attacks is very uncertain.

For this reason, more emphasis should be placed on regular food intake and sufficient food supply instead of composing stressful migraine diets for the entire family.

Behavioral medicine and general therapy measures

For children in particular, it is particularly important that headache therapy is not solely aimed at treating symptoms and critical illnesses. Rather, therapy must focus on this

– to maintain or restore mental and physical balance,

– to strengthen the organism functions and

– to prevent possible disease mechanisms.

The interaction between soul, mind and body must be examined in detail in order to prevent and treat headache disorders in children. These include factors such as

– stress,

– environment, social circumstances,

– Lifestyle habits and nutrition (detailed information ▶ Section 2.17).

Unhealthy lifestyle habits and behaviors must be identified and abandoned. To do this, perseverance and the will to change are essential. Behavioral measures are therefore particularly important in the treatment of headaches in children.

Physical stress

An important trigger for migraine attacks in children is physical overexertion and stress.

– Such factors can always have an effect when children e.g. sleeping too long or too short . In particular, irregular going to bed and irregular getting up should be avoided in children with migraines.

– A sudden change in food intake and eating behavior should also be avoided. This includes e.g. B. the hasty breakfast or even the skipped breakfast before school due to lying in bed for too long. In such situations, children typically get a headache around 9 a.m.

– But external factors that you have difficulty influencing yourself can also cause physical stress. These include high humidity in humid weather, extreme heat, sudden changes in the weather, poor air conditions due to poorly ventilated rooms, overheated living areas, strong smells, sudden changes in lighting conditions, noise, cold or drafts.

– Excessive sports activities can also lead to migraine attacks. On the one hand, this can cause blood sugar levels to drop sharply, and on the other hand, the physical stress can also trigger headaches. If children often complain of headaches or migraine attacks after gymnastics lessons, they should try to reduce their exertion during these sporting activities if possible. If possible, children should choose sports that do not require a very rapid change in physical activity. Ideally, swimming, running, cycling or other endurance sports suitable for this.

– Headaches in children can also be triggered by external pressure , e.g. B. through hairbands or tight headbands, hats or swimming goggles. Children who are susceptible should therefore avoid clothing that puts pressure on their heads. This also applies to hairbands with sharp thorns that impact the scalp, or elastic bands that hold braids or ponytails together.

Psychological stress

An irregular life, tension, fears, stress and psychological overload are the main potent triggers for migraine attacks in children.

Frequent television with often aggressive and stressful content, computer games, spending long periods of time on the Game Boy, loud, stimulating music and an extremely large number of appointments in the afternoon leisure program are everyday life for many children. All of these can trigger migraine attacks.

Therefore, children and parents should pay particular attention to a balanced and regular life. This primarily includes:

– a strict limitation of daily media consumption with the observance of fixed and limited television viewing times and equally limited time spent at the computer;

– Limiting leisure or afternoon events to a few but regular activities;

– Scheduled rest periods for relaxation with walks or games in a quiet environment.

Chemical irritants

Many chemical substances can cause headaches or migraine attacks if exposed to excessive amounts. This applies at home, at school or in other environments.

The following substances are particularly potent headache triggers: car exhaust fumes, cement dust, coal dust, dyes, factory exhaust gases, chlorinated hydrocarbons, formaldehyde, solvents in adhesives, paints and other materials (especially in many craft glues), flour dust, insecticides, gasoline and oil products, organic phosphate compounds, perfumes , deodorants, wood dust.

If these or other substances pose a problem, the best solution is to avoid exposure. Care must also be taken to ensure adequate ventilation of the rooms and fresh air.

Allergic reaction

Hay fever refers to allergic reactions to pollen from a wide variety of plants, which occur depending on the time of flowering. If there are permanent symptoms of irritation, then allergic reactions to other substances must be assumed. This particularly includes the allergy to house dust mite feces, the so-called house dust allergy. Other common allergies include hair, bird feathers and mold. , tearing, red eyes, runny or stuffy nose, itching and sneezing attacks often occur. If symptoms occur, an experienced allergist should be consulted to initiate specific testing and therapy.

Whenever possible, attempts must be made to avoid the irritant. The problem with house dust allergy can be reduced through adequate furnishing. This includes avoiding dust catchers such as curtains, upholstered furniture, carpeting, open shelves and natural bedding. It is better to use smooth surface structures that allow for damp wiping, e.g. E.g. furniture made of wood or with a leather cover, smooth PVC or parquet floors. In addition, the rooms should be ventilated frequently. If you are allergic to mold, drying out the rooms and using proper heating and ventilation can be particularly helpful. If you have pet allergies, special cleaning is required. Carpets and upholstery should be vacuumed as often as possible, and the vacuum cleaner should have an allergy filter.


Children with migraines are particularly sensitive to intense smells. It doesn't matter whether these smells are normally experienced as pleasant or unpleasant. Odorants that can cause particularly strong headaches can be found in tobacco smoke, room deodorants or, especially, perfumes. When children react with migraine attacks, one should always try to avoid such intense odor sources.

Light changes

Constantly changing changes in lighting conditions are also potent triggers of migraine attacks. Often - with good intentions - the desk is placed in front of a window in order to have as natural light as possible for working on homework. When the children look up from their desk, they look out the window into the bright light. The constant adaptation to the light and dark situation is a permanent stress factor for the nervous system. In addition, the child's brain has to repeatedly switch the eye from near vision to distance vision. Passing clouds also obscure the sunlight; when there are gaps in the clouds, the eye has to take the bright, dazzling light into account again. This constant change, together with the mental strain of solving homework, is an extremely potent trigger for headaches and migraine attacks. For this reason, the desk should always be placed against a wall and direct sunlight should be avoided. Of course, this also applies to adult workplaces.

If children suffer from migraine attacks particularly frequently at school, you should take a look at the child's seat at school and pay attention to whether unfavorable changing lighting conditions can be identified as a trigger for the migraine attacks. Moving the child around in the class can then significantly reduce the problem.

Similar problems arise when looking at sparkling water from the beach or when glitter of snow constantly enters your eye. Driving in a car looking into direct sunlight also has a similar effect.

In young people, flickering lights in discos combined with noise can also be a potent migraine trigger.

www.kopfschrei-schule.de – Stop headaches in children

Around half of children experience headaches and migraines at school, at home or in their free time. Six percent of them have headaches once a week or more often. Without early help, many of these children's headaches become more frequent or even permanent. New approaches to treatment and prevention show that there is an alternative to chronic pain and suffering: “Stop the Headache” and “Headache School”. The programs are implemented in collaboration with the Techniker Krankenkasse, the Kiel Pain Clinic, teachers and resident therapists. The aim is to relieve headaches in children and at the same time reduce or even eliminate the need for medication.

Stop the headache

“Stop the Headache” is aimed at children and young people between the ages of eight and fourteen who already suffer from headaches or migraines. You should be provided with up-to-date advice and treatment. The prerequisite for participation is a medical certificate stating that the child has been suffering from tension headaches or migraines for more than six months. The effectiveness of the program was proven in a study by the University of Göttingen: the number of headache days among the participating children can be significantly reduced through the treatment. Medication intake also decreased. The courses are started as needed. They take place in cooperating specialist practices. Further information is available from the course instructors. The addresses and further information can be found on the Internet at www.kopfschrei-schule.de

“Stop the Headache” uses modern psychological procedures and under the guidance of experienced course instructors to help reduce or eliminate chronic tension headaches or migraines in children and young people between the ages of eight and fourteen. The aim of the eight-week training is to treat the pain effectively before it becomes chronic and to train the students to become headache experts on their own behalf. The children's ability to help themselves is promoted. At the same time, professional medical diagnosis, advice and treatment are made possible in collaboration with the nationwide treatment network.

The course program is based on the experiences of a two-year study that the Techniker Krankenkasse carried out together with the universities of Göttingen and Düsseldorf. The results of the study clearly show that many affected children can be helped: around 60 percent of the participants, who usually suffered from headaches more frequently per week before the course, experienced a significant improvement in their illness. Medication intake also fell by around 40 percent.

The training at a glance

– Week 1: The Headache Viewer – Information about the pain

– Week 2: The relaxation boss – learning a relaxation exercise

– Week 3: The stress manager – identifying headache triggers

– Week 4: The Thought Specialist – Doom and Clairvoyance

– Week 5: The Attention Checker – Attention and Headaches

– Week 6: The I’m OK Master – Confident dealings with friends and family

– Week 7: The problem fighter – problem solving

– Week 8: The Headache Expert – Reviewing what you’ve learned and planning ahead

– Week 9: Final interview – child – parents – therapist

The TK provides each participant with the course materials and, as part of the reimbursement, covers the treatment costs for the children and young people insured with it. You can find out where courses are offered on the Internet at www.kopfschrei-schule.de

Three school hours against headaches and migraines

There are currently no measures or concepts for preventing headaches at school that are specifically aimed at teachers and students. This is all the more surprising since, according to studies carried out by the “Transparent School in Schleswig-Holstein” campaign (Institute for Addiction Prevention and Applied Psychology, Bremen), headaches are now one of the main health problems of school-age children. A representative survey of schools in Schleswig-Holstein found that, depending on the type of school, between 20 and 50% of students reported headaches as an important and persistent health problem. Headaches have increased in frequency by around 300% in the last 20 years!

In view of these facts, Frisch K. and Göbel H (2009) have developed a teaching unit that is available to all teachers to download free of charge via the Internet. There are currently no measures or concepts to prevent headaches at school that are specifically aimed at teachers and students. Teachers, students and parents should be comprehensively informed in order to achieve greater awareness of headache disorders in school-age children. Knowledge about headache disorders, recognizing the different forms and passing on various behavioral measures can lead to headaches being recognized early and special measures being initiated (talking to parents, involving specialists and doctors).

Here the school has a special health-promoting role to play. This includes:

– Information on how to organize a regular daily routine;

– occupational psychology instruction;

– Health teaching regarding adequate nutrition and sleep hygiene;

– Learning relaxation training in physical education classes as well

– Stress management techniques.

These measures are easy to carry out. Due to the known mechanisms that cause headaches, it is possible to intervene positively in the steady increase in headache prevalence in school-age children.

The homepage provides the following materials:

– Information and involvement of parents (letter to parents, possibly parents’ evening);

– specific information about headache disorders in children for the teacher;

– Implementation of the teaching series;

– Interdisciplinary learning with balancing and relaxation techniques in physical education lessons.

The teaching series consists of 3 double lessons. The overall goal of the series is to address health-damaging behaviors in the everyday context of young people and to provide solutions to avoid them. There should be no moralizing education here, but rather the young people should be enabled to recognize problems in their world that can cause headaches and to develop long-term behavior modification in the knowledge of the advantages of a balanced lifestyle. They should not be given the feeling that they have to justify their everyday life and thus share the blame for their headaches.

In order to achieve acceptance of the teaching material among the students, the lesson content is developed with the help of the comic character “Cap”. Here the young people can take action themselves and individually complete the tasks set. The knowledge gained is anchored in the memory for the long term. At the end of each unit, the results obtained should be recorded in writing.

A poster can be hung in the classroom to present the most important results of the teaching series. In this way, what has been learned is continually recalled. You can download all documents from the homepage www.kopfschrei-schule.de . The materials may be copied for school use.

Acute drug therapy

With regard to drug therapy, clear differences in adulthood . Especially with migraines in children, it is necessary that the medication is taken as early as possible

You first start with the gift of

– Antiemetic domperidone (10 mg orally or as a suppository),

to improve absorption and effect of the analgesic and initiate therapy for nausea and vomiting.

Very careful dosing must be carried out as severe dystonia can occur as undesirable side effects, especially in children. ocular crises , opisthotonus , dysarthria and trismus can occur. This applies even more when using metoclopramide .

Following the administration of domperidone, an analgesic may be administered after a period of 15 minutes. Paracetamol or ibuprofen are possible for young children under the age of 12.

Danger! Due to new study results, the previous general recommendation that children should be given paracetamol in case of pain or fever without any particular concerns can no longer be maintained. Please also read about this – Paracetamol: Current warning against taking it during pregnancy

In view of the possible risk of Reye's syndrome, the administration of acetylsalicylic acid should be avoided. In the case of school children, whose migraine attacks can occur at any time, especially at school in the morning, the teachers be informed accordingly. It is best if the doctor gives the student written instructions on what to do in the event of a migraine attack to present to the teacher.

Dihydroergotamine in tablet form (2 mg orally) can also be used to stop attacks in children whose attacks do not respond adequately to paracetamol and ibuprofen.

If nausea and vomiting are severe, antiemetics and analgesics can also be given suppositories

Ergotamine tartrate and triptans are not indicated in children under 12 years of age. For use in adolescents aged 12 and over, Imigran (sumatriptan) as a nasal spray 10 mg, or AscoTop (zolmitriptan) as a nasal spray 5 mg can also be used. The use of sumatriptan or zolmitriptan in adolescents should only be used as prescribed by a specialist or a doctor with extensive experience in migraine treatment and in accordance with local guidelines.

Drug prophylaxis

Prophylactic drug therapy in childhood is even more difficult and complicated than in adulthood.

In view of the possible high frequency of taking analgesics and severe suffering, prophylactic medication must also be considered in childhood if there are frequent migraine attacks. However, it must be borne in mind that side effects of prophylactics occur more frequently and more severely in children than in adults.

When it comes to prophylactic therapy, both in childhood and in adults, only monotherapy should be carried out and different medications should not be given in combination.

Primarily can occur in childhood

– a beta blocker,

such as metoprolol or propranolol can be used.

– Alternatives are flunarizine or pizotifen (no longer available in Germany, but can be ordered abroad).

– It must be clear that drug prophylaxis behavioral medicine prophylaxis and that one should always try to make intensive use of non-drug prophylactic measures.

– As a rule, behavioral measures produce the same or even better effects.

There is very contradictory information in the literature regarding the effectiveness of medicinal migraine prophylaxis Some of the study findings show significant effects, while other studies do not show such significant effects.

When considering drug prophylaxis in children, a short-term check should be made to see whether therapeutic effectiveness is achieved and how initial side effects can possibly be compensated for. This success checks at fortnightly intervals . It should only be continued if it is effective. The possible side effects must be discussed with parents and children and, if necessary, carefully recorded. If necessary, the therapy must be adjusted.

All of these precautionary measures show that prophylactic drug therapy for migraines in children should be avoided if possible

individual experiments ” may become necessary , especially for children who very serious and disabling attacks Sometimes surprising effects of prophylactic therapy procedures can actually be found. However, these are exceptions. In such problematic cases, treatment should, if possible, be carried out by an experienced neuropediatrician.

Even if rapid improvement in migraine cannot be achieved, it is necessary for patients and parents to receive repeated advice and hope for improvement in migraine. Spontaneous remission can occur again and again, especially in childhood.

Sometimes it only becomes apparent later on which trigger factors are particularly potent, and continuous recording and inquiry into possible trigger factors can achieve decisive improvement.

However, it is completely unsatisfactory and frustrating for children and parents when patients are discharged from the consultation without specific advice about current treatment options, with the information that migraines cannot be cured and that nothing can be found.