Headache in Children

Headache is one of the most common neurologic complaints prompting a visit to primary care, the emergency department, or a community pharmacy in children and adolescents. This chapter covers two primary headache disorders -- tension-type headache and migraine -- and one common secondary headache disorder, medication-overuse headache, which arises directly from the abortive medications used to treat the other two.^[1]

Pediatric migraine differs from the adult pattern in ways that matter clinically: attacks are often shorter (as brief as 2 hours), have a faster onset and offset, are more frequently bilateral rather than the classic adult unilateral pattern (often not becoming reliably unilateral until later adolescence), and present with more prominent gastrointestinal symptoms.^[2] A clinician applying the adult migraine pattern too literally can miss or misclassify pediatric migraine as tension-type headache, which changes both acute and preventive treatment selection. Because a minority of pediatric headache is secondary to a serious underlying cause -- and because children cannot always describe their symptoms as precisely as adults -- a structured red-flag screen is the highest-stakes step in every pediatric headache assessment, before any treatment decision is made.^[3]

The two primary headache disorders covered in this chapter are readily distinguished by pattern once a careful history is taken -- see the comparison table in Assessment & Diagnosis for a side-by-side breakdown used to tell them apart at the bedside.

A first-degree relative with migraine is common in pediatric migraine, so family history is a useful supporting clue. A group of childhood presentations historically called the childhood periodic syndromes -- now termed episodic syndromes that may be associated with migraine -- should also be asked about, since a history of one supports a migraine diagnosis even when the headache pattern alone is ambiguous:

• Benign paroxysmal torticollis
• Benign paroxysmal vertigo
• Recurrent gastrointestinal disturbance -- abdominal migraine and cyclic vomiting syndrome
• Infantile colic
• Alternating hemiplegia of childhood
• Vestibular migraine

Other conditions occurring more often in children with migraine include motion sickness, sleepwalking, sleep talking or bruxism (teeth grinding/clenching), growing pains, and cold-stimulus headache.

• First-degree relative with migraine -- family history is common in pediatric migraine, particularly when aura is present.
• Psychiatric comorbidity -- anxiety, depression, and adverse childhood experiences are more common in children and adolescents with migraine and should be screened for at diagnosis, not just when treatment fails.
• A history of one of the episodic syndromes that may be associated with migraine (see Recognize the Condition).
• Poor sleep hygiene -- insufficient or excessive sleep, irregular sleep-wake schedule.
• Skipping meals or prolonged fasting; dehydration.
• Caffeine use, and caffeine withdrawal.
• Excessive screen time and poor stress-management/coping skills.
• Female sex, particularly after puberty; a relationship to the menstrual cycle in postmenarchal adolescents.
• Obesity.
• Frequent use of abortive headache medication -- the key modifiable risk factor for developing medication-overuse headache.

Distinguishing tension-type headache from migraine

History

History is the key diagnostic tool and should be obtained from both the child and a parent/caregiver -- focus on the child's own report, using the parent for clarification and supporting detail. A headache diary kept by the family helps identify triggers, pattern, and treatment response over time.^[2]

• Headache-specific features: onset, progression, quality, duration, frequency, location, and relieving/aggravating factors such as physical activity or positional change.
• Triggers: skipping meals, sleep loss or excess, dehydration, caffeine, exercise, relation to menstruation, weather, anxiety/stress.
• Associated symptoms: nausea, vomiting, photophobia, phonophobia, osmophobia, sensitivity to movement.
• Conditions occurring in migraine patients: motion sickness, sleepwalking, sleep talking or bruxism, growing pains, cold-stimulus headache, and others (see Recognize the Condition).
• Development: growth curve, academic function and behaviour, developmental delay, learning disabilities.
• Psychiatric comorbidities: screen for mood disorders, anxiety, depression, and adverse childhood experiences.
• Episodic syndromes that may be associated with migraine (see Recognize the Condition).
• Family history: migraine (particularly with aura, which tends to be familial), early stroke, clotting or bleeding disorders including a history of frequent miscarriage, intracranial aneurysm, or neoplasia.
• Medications: nonprescription and prescription medication use, including frequency -- confidentially screen adolescents for substance use, including cannabis.
• Disability: the degree of interference with school and social function, ideally quantified with a validated tool such as PedMIDAS.^[4]

Physical examination

• Blood pressure and vital signs; palpation of the sinuses; examination of the teeth; assessment for neck stiffness; auscultation for carotid and cranial bruits.
• Height, weight, and head circumference, plotted on a growth curve.
• A thorough neurologic examination, including cranial nerves with fundoscopy, motor power testing including pronator drift, deep tendon reflexes, Babinski testing, tandem gait, and coordination testing.

Investigations

Obtain neuroimaging when a red flag is present (see Red Flags & Refer) -- an abnormal neurologic examination, recent onset of severe headache, a change in headache type or pattern, neurologic dysfunction, or systemic signs/symptoms.^[3]

Lumbar puncture is indicated when an infectious or inflammatory process is suspected, or to measure opening pressure when idiopathic intracranial hypertension is a possibility. When raised intracranial pressure is suspected, perform lumbar puncture only after neuroimaging has excluded a contraindication (e.g., a mass lesion) -- MRI with vessel imaging (MRA for suspected aneurysm, MRV for suspected venous thrombosis) and contrast (for suspected low-pressure headache from a CSF leak) may be added based on the specific concern.

• Reach an accurate diagnosis -- correctly distinguishing tension-type headache, migraine, and medication-overuse headache, and excluding secondary causes.
• Relieve or abort pain and associated symptoms (nausea, vomiting, photophobia/phonophobia) with each acute attack.
• Prevent medication overuse by keeping abortive-medication use under the frequency limits that trigger medication-overuse headache.
• Develop adaptive pain-coping strategies rather than relying on medication alone.
• Decrease headache-related disability and school/social absenteeism.
• Prevent progression from episodic to chronic headache.
• Improve health-related quality of life.
• For preventive therapy specifically: achieve at least a 50% reduction in attack frequency, severity, and duration; improve responsiveness to acute treatment; and reduce disability.^[6]

• Provide reassurance, information, and age-appropriate education about the headache diagnosis to both the patient and family.
• Keep a headache diary to track triggers, pattern, frequency, severity, and response to treatment -- useful for both management and follow-up.
• Identify and, where practical, avoid specific triggers: skipping meals or prolonged fasting, insufficient or excessive sleep, dehydration, caffeine use or withdrawal, stress and stress let-down, and -- in postmenarchal adolescents -- the menstrual cycle.
• Optimize sleep hygiene: a regular sleep-wake schedule, and avoiding daytime napping.
• Maintain adequate hydration and regular meals; eat a protein-containing meal within 30-60 minutes of waking, since low blood sugar can trigger migraine.
• Encourage regular physical exercise.
• Moderate recreational screen time, and encourage screen breaks -- excessive screen time is a commonly reported aggravating factor.
• Cognitive behavioural therapy, mindfulness, biofeedback, and relaxation training are all effective adjuncts; for migraine specifically, CBT combined with amitriptyline has the strongest supporting evidence for preventive benefit.^[6]
• Noninvasive neurostimulation devices (transcranial magnetic stimulation, remote electrical nerve stimulation, non-invasive vagal nerve stimulation) are used in pediatrics; only non-invasive vagal nerve stimulation is Health Canada-approved for adolescent migraine treatment, and cost is a practical barrier to all of these devices.
• Encourage taking abortive medication as early as possible in the attack -- within 30-60 minutes of onset -- since this meaningfully improves response.
• Occipital nerve blocks, administered by a specialist, are used as bridge therapy for severe headache refractory to acute medications or short-term preventive therapy.^[7]

Pregnancy

Relevant primarily to postmenarchal adolescents. Acetaminophen is the preferred acute analgesic in pregnancy. NSAIDs (ibuprofen, naproxen) should be avoided in the third trimester and used only intermittently, with caution, earlier in pregnancy. Sumatriptan has the largest pregnancy safety database among the triptans and is generally preferred if a triptan is needed; data for the other triptans are more limited. Topiramate and divalproex sodium are teratogenic and are not preferred preventive choices in a patient of childbearing potential -- if either is used despite this, ensure effective contraception is in place and counsel explicitly that topiramate can reduce the efficacy of combined hormonal contraceptives at doses over 200 mg/day. Candesartan (an ARB) is contraindicated in pregnancy. Discuss contraception and pregnancy planning directly with every adolescent started on a potentially teratogenic preventive agent.

Breastfeeding

Acetaminophen and ibuprofen are compatible with breastfeeding. Data on triptans and most preventive agents in lactation are limited; involve the prescriber before continuing a preventive medication through breastfeeding in an adolescent parent.

Younger children (under about 6-12 years)

Fewer acute and preventive options have pediatric-specific evidence at this age. Rizatriptan has the youngest supporting evidence among triptans (as young as 6 years, off-label in Canada); almotriptan is not approved under 12 years. Cyproheptadine is often preferred for prevention in younger children given a more favourable tolerability profile at this age; sedation and weight gain increasingly limit its use as children get older. Weight-based (not fixed adult) dosing is essential throughout this age range.

Psychiatric comorbidity

Screen for anxiety, depression, and suicidal ideation at diagnosis and at follow-up -- these are more common in children and adolescents with migraine. Amitriptyline carries an increased suicidality risk that must be discussed explicitly with the patient and family before starting it, and monitored for throughout treatment.

Renal/hepatic considerations

Topiramate is associated with renal stones and a metabolic acidosis risk -- use caution in any pre-existing renal impairment. Divalproex sodium carries a rare but serious hepatotoxicity risk and requires baseline and periodic liver enzyme monitoring. NSAIDs should be avoided or used with caution in renal dysfunction and with adequate hydration. Memantine dosing should be reconsidered if there is a renal concern -- obtain a baseline serum creatinine.

Comorbid conditions affecting preventive-agent choice

Avoid propranolol in asthma/reactive airway disease, insulin-dependent diabetes (masks hypoglycemia symptoms), and bradyarrhythmia. Consider topiramate preferentially over amitriptyline, flunarizine, or cyproheptadine when weight gain is a specific concern (topiramate causes weight loss; the others cause weight gain). Consider venlafaxine or amitriptyline when comorbid anxiety or depression is present, with careful suicidality monitoring for amitriptyline specifically.

Have the patient/family maintain a headache diary throughout treatment -- it is the single most useful tool for judging whether an acute or preventive strategy is actually working, and for spotting an emerging medication-overuse pattern early.

Reassess disability formally with a tool such as PedMIDAS at diagnosis and at follow-up to track functional improvement, not just headache counts.^[4]

For preventive therapy: slow titration over 4-12 weeks to the lowest effective dose is standard, and it is essential to tell the patient/family in advance that response is not rapid -- a meaningful response typically takes 2-3 months once a therapeutic dose is reached; nutraceuticals specifically may take up to 3 months. Reassess formally at that point before concluding a preventive agent has failed.

Monitor topiramate for cognitive slowing, weight loss, and symptoms of renal stones or metabolic acidosis. Monitor divalproex sodium with baseline and periodic liver enzymes and a CBC. Monitor amitriptyline for anticholinergic effects, QTc prolongation risk with other prolonging drugs, and -- specifically and explicitly -- suicidality. Monitor propranolol for bradycardia, hypotension, and depressive symptoms, which are under-reported in adolescents. For candesartan, obtain a comprehensive metabolic panel at baseline and again 2 weeks after reaching the goal dose. For fremanezumab, monitor for injection-site reactions and hypersensitivity.

Once a predefined treatment goal -- commonly 3 or fewer headaches per month sustained for 6-12 months -- is achieved, a slow taper and possible discontinuation of the preventive medication can be attempted; meaningful improvement can persist even after stopping.

At every follow-up, explicitly ask about the frequency of abortive-medication use in days per month -- this is the single most effective way to catch emerging medication-overuse headache before it becomes established.

1. Reconfirm the diagnosis -- recheck for red flags, re-examine, and reconsider whether the headache truly meets tension-type or migraine criteria, or whether a change in pattern has occurred that now warrants neuroimaging.
2. For acute treatment failure: confirm the medication was taken early in the attack (within 30-60 minutes of onset), at an adequate weight-based dose, and confirm whether nausea/vomiting is limiting oral absorption -- if so, add an antiemetic or use a non-oral route (nasal triptan).
3. Screen explicitly for medication-overuse headache -- ask about days-per-month of abortive medication use before assuming an acute or preventive agent has simply stopped working.
4. If an analgesic alone is inadequate for migraine, escalate to a triptan; if triptan monotherapy is inadequate, consider the sumatriptan/naproxen combination.
5. For preventive treatment failure: confirm an adequate dose and an adequate trial duration (up to 3 months for nutraceuticals, 2-3 months at a therapeutic dose for prescription preventives) before concluding failure -- many perceived failures are actually inadequate trials.
6. If a first preventive agent genuinely fails an adequate trial, switch to a different class based on comorbidities (see Special Populations) rather than simply increasing the dose further.
7. For medication-overuse headache: educate the patient/family, withdraw the overused abortive agent (bridging with naproxen if needed), and start a preventive agent concurrently to support the withdrawal period.
8. For refractory disabling migraine that has failed 2 or more adequate preventive trials in a postpubescent patient: refer to a pediatric neurology/headache specialist to consider fremanezumab, other specialist-directed CGRP-targeted therapy, onabotulinumtoxinA, or a nerve block as bridge therapy.^[9]

• Using ASA, or an ASA-containing combination product, in a patient under 15 years of age -- Reye syndrome risk.
• Ordering routine neuroimaging in a child with a normal neurologic examination and no red flags -- this does not improve outcomes and delays appropriate management.^[5]
• Missing an emerging medication-overuse headache pattern by not specifically asking about days-per-month of abortive medication use at follow-up.
• Delaying acute treatment until the pain is already severe -- treating early in the attack meaningfully improves response.
• Using opioid analgesics or butalbital-containing combination products for migraine.
• Starting a dopamine-antagonist antiemetic (metoclopramide, prochlorperazine, chlorpromazine) without considering diphenhydramine co-administration to reduce extrapyramidal risk.
• Presenting amitriptyline or topiramate to families as guaranteed to work for prevention, without mentioning that a large placebo-controlled pediatric trial found neither outperformed placebo on headache-frequency reduction.^[8]
• Prescribing a triptan without screening for cardiovascular disease, uncontrolled hypertension, or basilar/hemiplegic migraine, or without checking the interval since a prior triptan or ergot dose.
• Starting topiramate or divalproex sodium in an adolescent of childbearing potential without discussing teratogenicity and contraception.
• Forgetting that fixed adult dosing does not apply -- every acute and preventive medication in this chapter needs weight-based dosing in children.
• Failing to screen for anxiety, depression, and suicidal ideation, particularly before and during amitriptyline therapy.

How to use this table: Doses are pediatric weight-based doses and require patient-specific confirmation, including a maximum not to exceed the adult dose and renal/hepatic adjustment where relevant. Select any drug name to open its complete Pharmasist Drug Database page.

Analgesics

Intermittent oral analgesics, given as early as possible in the attack, are the mainstay of abortive therapy for both tension-type headache and migraine. Limit use to under 15 days per month to avoid medication-overuse headache.

Antiemetics

Used for nausea/vomiting associated with migraine; dopamine-antagonist agents are often combined with diphenhydramine to reduce extrapyramidal risk.

Ergot derivatives

Limited pediatric use given a narrower evidence base and drug-interaction burden than triptans.

Triptans

All triptans: contraindicated in cardiovascular disease, severe peripheral vascular disease, ischemic bowel disease, and cardiac accessory conduction pathway disorders; avoid within 24 hours of another triptan or an ergot derivative; use caution with SSRIs/SNRIs given serotonin syndrome risk; limit to under 10 days/month to avoid medication-overuse headache. Only almotriptan is Health Canada-approved for pediatric use (adolescents 12 years and older) -- the others are used off-label based on supporting clinical evidence.

Triptan/NSAID combination

Alternative acute therapy

Preventive: Angiotensin receptor blockers

Preventive: Antiepileptics

Preventive: Antihistamines

Preventive: Beta-1-adrenergic antagonists

Preventive: Calcium channel blockers

Preventive: NMDA receptor antagonists

Preventive: Serotonin antagonists

Preventive: Serotonin-norepinephrine reuptake inhibitors

Preventive: Tricyclic antidepressants

Preventive: CGRP-targeted therapy

Fremanezumab is the first and only Health Canada-approved CGRP-targeted preventive therapy for pediatric migraine (episodic migraine, 6-17 years and 45 kg or more) as of 2026. The other CGRP monoclonal antibodies (erenumab, galcanezumab, eptinezumab) and the oral gepants (atogepant, rimegepant, ubrogepant) remain without a pediatric indication in Canada and are used only investigationally or under specialist direction in select refractory postpubescent patients who have failed 2 or more standard preventive trials -- pediatric-specific dosing for these agents is not yet established.

Preventive: Nutraceuticals

Often favoured as a first preventive step given a favourable benefit-risk ratio despite generally low-quality supporting evidence. Choose products from a reputable, Good Manufacturing Practices-certified manufacturer carrying a valid Health Canada Natural Product Number (NPN). May take up to 3 months for significant benefit.