Headache in Children
Clinical Snapshot
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]
Recognize the Condition
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.
Primary and secondary headache patterns in children
Tension-type headache
Mild to moderate, bilateral, pressing or tightening (non-pulsatile) pain lasting anywhere from 30 minutes to 7 days. Not aggravated by routine physical activity, and not typically associated with nausea, vomiting, or more than one of photophobia/phonophobia. Classified as episodic-infrequent, episodic-frequent, or chronic based on the number of headache days.[1]
Migraine
Moderate to severe pain, throbbing or non-throbbing, typically frontotemporal and -- unlike the classic adult pattern -- often bilateral until later adolescence. Aggravated by routine physical activity. Attack duration is typically 2-72 hours but can be as short as 2 hours in children, and is faster in onset and offset than adult migraine. Photophobia, phonophobia, nausea, and/or vomiting are common; young children who cannot reliably report these symptoms may show them behaviourally instead -- resting in a dark, quiet room suggests photophobia/phonophobia. Most pediatric migraine occurs without aura; when aura occurs, visual symptoms (scintillations, scotoma) are most common, followed by sensory (numbness, tingling) and speech symptoms.[1][2]
Medication-overuse headache
A secondary headache disorder -- headache occurring on 15 or more days per month, developing in a patient with a pre-existing primary headache disorder (usually migraine) who has been regularly overusing abortive medication for more than 3 months. It is a genuine, common, and under-recognized risk of the same abortive therapy used to treat migraine and tension-type headache, and it worsens the underlying primary headache disorder rather than simply adding to it.
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.
Risk Factors
- 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.
Red Flags & Refer
Any of the following warrants urgent neuroimaging and/or specialist (pediatric neurology or emergency medicine) evaluation rather than management as a primary headache disorder:[3]
- Sudden, severe "thunderclap" headache reaching maximum intensity within seconds to minutes.
- Headache with fever and neck stiffness, suggesting meningitis or another CNS infection.
- Headache that worsens with straining, coughing, or lying down, or is associated with morning vomiting -- both suggestive of raised intracranial pressure.
- New focal neurologic deficit, including cranial nerve findings, weakness, abnormal gait/coordination, or a positive Babinski sign.
- Headache in a very young child, or a rapidly progressive headache pattern.
- Papilledema on fundoscopic examination.
- New seizure or altered level of consciousness accompanying the headache.
- Abnormal growth trajectory -- an accelerating head circumference, or falling off the growth curve.
- The first or worst headache of the patient's life, or a distinct change in pattern from a previously stable, diagnosed headache disorder.
- Recent significant head trauma, or a history of malignancy, immunocompromise, or a ventriculoperitoneal shunt.
Assessment & Diagnosis
Distinguishing tension-type headache from migraine
| Parameter | Tension-type headache | Migraine |
|---|---|---|
| Duration | 30 minutes to 7 days | 2-72 hours (can be as short as 2 hours in children) |
| Laterality | Bilateral | Often bilateral until later adolescence; unilateral pattern emerges over time |
| Character | Pressing or tightening, non-pulsatile | Throbbing (can also be non-throbbing) |
| Severity | Mild to moderate | Moderate to severe |
| Effect of physical activity | Not aggravated | Aggravated -- child avoids or stops activity |
| Nausea/vomiting | Absent or minimal | Common |
| Photophobia/phonophobia | At most one of the two | Often both; young children may show this behaviourally (seeking a dark, quiet room) |
| Aura | Absent | Absent in most pediatric cases; when present, usually visual, then sensory or speech |
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.
Treatment Targets
- 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]
Choose Initial Treatment
Acute (abortive) treatment
1st line, tension-type headache acetaminophen or ibuprofen at a weight-based dose, given as early as possible in the attack.
1st line, migraine ibuprofen at a weight-based dose -- it has stronger evidence than acetaminophen for acute pediatric migraine and is the analgesic recommended by current pediatric guidelines.[2]
Avoid ASA in patients under 15 years of age given the risk of Reye syndrome, and avoid combination products containing ASA, caffeine, and butalbital ± codeine -- these carry the same Reye syndrome risk and a specific propensity to cause medication-overuse headache.
Add an antiemetic -- metoclopramide, prochlorperazine, or chlorpromazine (each ideally combined with diphenhydramine to reduce extrapyramidal risk), or ondansetron as a non-sedating alternative -- whenever nausea or vomiting is prominent enough to be disabling or to prevent oral analgesic intake.
2nd line -- use when analgesic monotherapy fails, or attacks are frequent, disabling, and moderate-to-severe a triptan. Almotriptan is the only triptan Health Canada-approved for adolescents (12-17 years); the other triptans are used off-label but have real supporting evidence, best for nasal zolmitriptan or sumatriptan in adolescents and oral rizatriptan in children as young as 6 years.[2]
Alternative -- when triptan monotherapy is insufficient the sumatriptan/naproxen combination tablet, in patients 12 years of age and older who weigh at least 50 kg.
Do not use opioid analgesics for migraine -- there is no good evidence of efficacy and a real risk of overuse.[7]
Preventive therapy
Start preventive therapy when migraine occurs 6 or more days per month of any severity, or 3-4 or more severe days per month, or is causing significant school/functional disability -- regardless of the specific count, disabling or highly disruptive migraine is itself a trigger to start preventive therapy.
1st line cognitive behavioural therapy, together with a nutraceutical (magnesium, coenzyme Q10, riboflavin, or melatonin) -- favoured as a starting point given a favourable benefit-risk ratio, despite low-quality evidence for efficacy.[6]
2nd line -- when nutraceuticals and CBT alone remain insufficient after an adequate trial propranolol, topiramate, or amitriptyline (amitriptyline specifically combined with CBT). Selection should be individualized to comorbidities -- see Special Populations -- since a large placebo-controlled pediatric trial found that neither amitriptyline nor topiramate outperformed placebo on headache-frequency reduction, while both caused more side effects than placebo; discuss this honestly with the patient and family as part of a genuine shared decision, rather than presenting these agents as guaranteed to work.[8]
Special situation -- younger children, or intolerance/contraindication to the above cyproheptadine (particularly useful under about 6 years of age), flunarizine, or pizotifen.
Special situation -- refractory episodic migraine, postpubescent, 6-17 years and at least 45 kg, after failing standard preventive options fremanezumab, the first and only Health Canada-approved CGRP-targeted preventive therapy in this population -- initiate under specialist direction.[9]
Medication-overuse headache
Manage medication-overuse headache with education plus gradual withdrawal of the overused abortive medication, bridging with naproxen if needed, and starting a preventive agent concurrently -- see Drug Tables and Treatment Failure/Next Step.
Non-Pharmacologic Treatment
- 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]
Special Populations
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.
Monitoring & Follow-Up
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.
Common Errors to Avoid
- 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.
Clinical Decision Algorithm
Drug Tables
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.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Acetaminophen | Dosing: 10-15 mg/kg/dose PO Q4H PRN Maximum: 75 mg/kg/day, up to 4000 mg/day | GI upset; hepatotoxicity in overdose | Can increase INR in patients on warfarin -- check INR if used at 2 g/day or more for 3 or more consecutive days | Used for tension-type headache and migraine. |
| Ibuprofen | Dosing: 5-10 mg/kg/dose PO up to 4 times daily Maximum: 40 mg/kg/day, up to 1200 mg/day | GI upset (most common when single doses are used for acute headache); avoid with vomiting, diarrhea, or dehydration given acute kidney injury risk | Increased anticoagulant effect and bleeding risk with warfarin, SSRIs, TCAs, or corticosteroids | Used for tension-type headache and migraine; stronger acute-migraine evidence than acetaminophen. Avoid in renal dysfunction or a history of peptic ulcer disease; use caution in inflammatory bowel disease and asthma. |
| Naproxen / naproxen sodium | Tension-type headache/migraine (age over 2y): 5-7 mg/kg/dose PO Q8-12H PRN, up to 1000-1100 mg/day Medication-overuse headache bridge (age over 2y): 5-7 mg/kg/dose PO BID for 4-7 days, up to 2 weeks | GI upset; same caution profile as ibuprofen with frequent use | Increased anticoagulant effect and bleeding risk with warfarin, SSRIs, TCAs, or corticosteroids | Longer-acting than ibuprofen -- clinical experience suggests a lower rebound-headache risk. Also used as bridge therapy when withdrawing an overused abortive medication. |
| ASA (acetylsalicylic acid) | All pediatric ages: Avoided for headache -- see Comments | Reye syndrome in children/adolescents with a concurrent viral illness | Increased bleeding risk with anticoagulants and other NSAIDs | Not used for headache under 18 years of age given Reye syndrome risk -- this includes combination products containing ASA, caffeine, and butalbital ± codeine, which also carry a specific propensity to cause medication-overuse headache. |
Antiemetics
Used for nausea/vomiting associated with migraine; dopamine-antagonist agents are often combined with diphenhydramine to reduce extrapyramidal risk.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Metoclopramide | Oral: 0.1-0.2 mg/kg/dose PO Q6-8H PRN, maximum 10 mg/dose Intravenous (emergency department): Per institutional protocol | Extrapyramidal symptoms, akathisia, sedation, hyperprolactinemia | Additive sedation with other CNS depressants | First-line IV antiemetic for acute migraine in the emergency department; oral dosing for outpatient use. |
| Prochlorperazine | Weight over 10 kg: 0.1 mg/kg PO Q6-8H, usual 2.5-5 mg/dose, maximum 10 mg/dose | Extrapyramidal symptoms, QTc prolongation | Additive sedation with other CNS depressants | Parenteral formulations no longer available in Canada; oral only. Recommended in combination with diphenhydramine. |
| Chlorpromazine | Dosing: 0.5-1 mg/kg PO Q8H, maximum 25 mg/dose | Hypotension, anticholinergic effects, sedation, extrapyramidal symptoms, QTc prolongation | Additive sedation with other CNS depressants; moderate CYP2D6 inhibitor | Parenteral formulations no longer available in Canada; oral only. Recommended in combination with diphenhydramine. |
| Diphenhydramine | Dosing: 1 mg/kg PO Q6H, maximum 50 mg/dose | Sedation, dry mouth, constipation, urinary retention, blurred vision; paradoxical excitation in children | Additive sedation with alcohol and other CNS depressants | Given to prevent or treat extrapyramidal symptoms from dopamine-antagonist antiemetics, not as a primary antiemetic itself. |
| Ondansetron | Dosing: 0.15 mg/kg PO, maximum 8 mg/dose | Headache, constipation, diarrhea, sedation, bradycardia, QTc prolongation | May decrease the analgesic effect of tramadol; CYP3A4 inducers decrease ondansetron levels; serotonin syndrome risk with other serotonergic drugs | Non-sedating option with no extrapyramidal risk. |
Ergot derivatives
Limited pediatric use given a narrower evidence base and drug-interaction burden than triptans.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Dihydroergotamine (nasal spray) | Age over 6y: 1 spray (0.5 mg) into each nostril at onset; may repeat once after 15 minutes if required | Nausea, taste disturbance, rhinitis | Contraindicated with potent CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, ketoconazole, ritonavir); do not use within 24 hours of a triptan given serotonin syndrome risk | Contraindicated in complicated migraine (basilar, hemiplegic), coronary heart disease, and uncontrolled blood pressure/ECG abnormality. Limit to under 10 days/month. |
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.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Almotriptan | Age 12-17y: 6.25-12.5 mg PO at onset; may repeat once after 2 hours; maximum 2 doses or 25 mg/24h | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms | Do not combine with an MAOI; CYP3A4 inhibitors may increase almotriptan levels | The only Health Canada-approved triptan for adolescents. |
| Eletriptan | Age 12-17y (off-label): 20-40 mg PO at onset; may repeat after 2 hours if initial dose was 20 mg; maximum 40 mg/24h (up to 80 mg/day in older adolescents) | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms | Contraindicated within 72 hours of a potent CYP3A4 inhibitor (e.g., clarithromycin, itraconazole, ketoconazole, ritonavir) | Off-label pediatric use. |
| Frovatriptan | Age 12-17y (off-label): 2.5 mg PO at onset; may repeat once after 4 hours; maximum 5 mg/24h | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms | Oral contraceptives and propranolol may increase frovatriptan levels | No pediatric-specific efficacy data available; off-label use. Longest half-life of the triptans. |
| Naratriptan | Age 12-17y (off-label): 1 mg PO at onset; may repeat once after 4 hours; maximum 5 mg/24h | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms | None specific beyond the class effects above | May be associated with fewer side effects than other triptans; off-label pediatric use. |
| Rizatriptan | Age 6y and older (off-label): 5 mg PO (tablet or orally disintegrating wafer) at onset; may repeat after 2 hours; maximum 10 mg/24h | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms | Do not combine with an MAOI; use caution with propranolol (increases rizatriptan bioavailability) | Best pediatric evidence among oral triptans; wafer form can be taken without water. |
| Sumatriptan | Age 12-17y (off-label): 25 mg PO tablet or 20 mg intranasal at onset; may repeat after 2 hours; maximum 2 doses/24h | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms; nasal spray may cause taste disturbance | Do not combine with an MAOI | Best evidence among nasal-spray formulations in adolescents; oral tablet also used off-label; subcutaneous injection not adequately studied pediatrically. |
| Zolmitriptan | Age 12-17y (off-label): 2.5-5 mg PO tablet/orally disintegrating tablet or nasal spray at onset; may repeat after 2 hours; maximum 2 doses or 5-10 mg/24h | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms; nasal spray may cause taste disturbance | Do not combine with an MAOI; maximum 5 mg/24h if also taking fluvoxamine or cimetidine | Nasal-spray formulation has good pediatric evidence; orally disintegrating tablet can be taken without water. |
Triptan/NSAID combination
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Sumatriptan/naproxen sodium | Age 12-17y and weight 50 kg or more (off-label): 1 tablet (sumatriptan 85 mg/naproxen 500 mg) PO at onset; maximum 1 tablet/day | Chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms, GI upset | Do not combine with an MAOI; increased anticoagulant effect and bleeding risk with warfarin, SSRIs, TCAs, or corticosteroids | Fixed combination with supporting evidence specifically in adolescents when triptan monotherapy alone is insufficient. |
Alternative acute therapy
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Lidocaine (intranasal, off-label) | Age over 6y (off-label): 20 mg (1 mL of 2% lidocaine solution) intranasal, 0.5 mL to each nostril | Nasal irritation, taste disturbance | None significant at intranasal doses | Off-label intranasal use of the injectable 2% solution, delivered via an atomizer device. Reserve for patients who cannot tolerate oral medication or who are vomiting. |
Preventive: Angiotensin receptor blockers
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Candesartan | Adolescents: Start 2 mg PO once daily, increase by 2 mg every 2 weeks to 8 mg once daily; may increase to 16 mg/day if tolerated after 2-3 months | Hypotension, dizziness, fatigue, GI upset, backache, hyperkalemia, renal insufficiency, rare angioedema | Increased renal dysfunction risk with NSAIDs; may raise lithium levels | Teratogenic -- not the preferred choice in patients of childbearing potential. Monitor comprehensive metabolic panel at baseline and 2 weeks after the goal dose. |
Preventive: Antiepileptics
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Topiramate | Age 13-18y: Start 12.5-25 mg PO HS, increase by 12.5-25 mg every 1-2 weeks to 100 mg/day in 1-2 divided doses | Somnolence, anorexia, weight loss, paresthesias; less commonly psychomotor slowing, metabolic acidosis | May decrease efficacy of hormonal contraceptives, particularly at doses over 200 mg/day | Potentially teratogenic -- not the preferred choice in patients of childbearing potential. See the CHAMP trial evidence context in Choose Initial Treatment. |
| Divalproex sodium | Adolescents and children: Start 250 mg PO HS, increase by 250 mg/week to a target of 1000 mg/day or 15-30 mg/kg/day in 1-2 divided doses | Nausea, weight gain, tremor, hair loss, blood dyscrasias, rare hepatotoxicity, edema, menstrual irregularities | Inhibits CYP2C9 and may increase levels of substrates (e.g., fluoxetine, phenytoin, warfarin); avoid with alcohol or other CNS depressants | Rarely used given tolerability and monitoring burden. Teratogenic -- not the preferred choice in patients of childbearing potential. |
Preventive: Antihistamines
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Cyproheptadine | Age over 3y: 0.1-0.2 mg/kg/dose PO BID, maximum 0.5 mg/kg/day Age 2-6y (alternative fixed dosing): 2 mg PO Q8-12H, maximum 12 mg/day Age 7-14y (alternative fixed dosing): 4 mg PO Q8-12H, maximum 16 mg/day | Sedation, weight gain, dry mouth, dizziness; paradoxical excitation possible in young children | Additive sedation with alcohol/CNS depressants; contraindicated with an MAOI | More useful in younger children; use in older children/adolescents limited by sedation and weight gain. |
Preventive: Beta-1-adrenergic antagonists
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Propranolol | Dosing: 0.6-1.5 mg/kg/day PO in 2-3 divided doses Maximum, weight 35 kg or under: 10-20 mg TID PO Maximum, weight over 35 kg: 20-40 mg TID PO | Fatigue, bradycardia, hypotension, depression (under-reported in adolescents) | Antacids may decrease absorption | Contraindicated in asthma, diabetes, heart block, and bradyarrhythmia. Avoid abrupt withdrawal. |
Preventive: Calcium channel blockers
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Flunarizine | Weight under 40 kg: 5 mg/day PO Weight over 40 kg: 5-10 mg/day PO | Sedation/drowsiness, weight gain, fatigue; extrapyramidal symptoms and depression with longer use | Additive sedation with alcohol/CNS depressants; caution with other drugs causing extrapyramidal symptoms | May take several weeks to be effective. Contraindicated in depression or a pre-existing extrapyramidal disorder. Very long half-life -- avoid frequent dose changes. |
Preventive: NMDA receptor antagonists
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Memantine | Adolescents: Start 5 mg PO BID; may increase to 10 mg BID if tolerated | Generally well tolerated; fatigue may occur | None significant | Typically used after failing other preventive medications; may be more useful in patients with aura. Obtain a baseline serum creatinine if renal concerns are present. |
Preventive: Serotonin antagonists
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Pizotifen | Dosing: 0.5-1 mg PO HS, titrated slowly Maximum: 1.5 mg/day in divided doses | Sedation, weight gain | Avoid with alcohol/CNS depressants; do not combine with an MAOI | Not commonly used. Start slowly and increase over 1-3 weeks. |
Preventive: Serotonin-norepinephrine reuptake inhibitors
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Venlafaxine | Adolescents: Start 37.5 mg PO QAM, increase by 37.5 mg every 2 weeks to a goal of 150 mg/day | Nausea, sleep disturbance, drowsiness, nervousness, dizziness, dry mouth; dose-related hypertension, particularly at 225 mg/day or more | Potentially fatal reaction with MAOIs; CYP2D6/CYP3A4 inhibitors (e.g., bupropion, clarithromycin, erythromycin, ketoconazole, quinidine, ritonavir) may increase venlafaxine levels | May be useful for patients with comorbid anxiety or depression. Taper to discontinue rather than stopping abruptly. |
Preventive: Tricyclic antidepressants
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Amitriptyline | Dosing: 0.25 mg/kg/day PO HS, increase by 0.25 mg/kg/day every 2 weeks Maximum: 1 mg/kg/day | Weight gain, drowsiness, anticholinergic symptoms (dry mouth, constipation); QTc prolongation risk with other prolonging agents | Metabolized by cytochrome P450 -- clearance affected by inhibitors (e.g., erythromycin, fluoxetine, ketoconazole, valproic acid) and inducers (e.g., carbamazepine, phenytoin) | Contraindicated in significant cardiac disease or hypotension. Recommended in combination with CBT. See the CHAMP trial evidence context in Choose Initial Treatment. |
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.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Fremanezumab | Age 6-17y and weight 45 kg or more: 225 mg subcutaneous injection once monthly | Injection-site reaction; rare hypersensitivity (rash, pruritus, urticaria) | Not metabolized by cytochrome P450 enzymes -- interactions with CYP substrates/inducers/inhibitors are unlikely | Reserve for refractory episodic migraine in this age/weight group, initiated under specialist direction. No starting/loading dose is required. |
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.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Coenzyme Q10 | Dosing: 1-3 mg/kg/day PO divided 2-3 times daily | Generally well tolerated; mild GI upset, minimized by dividing the dose with food | May reduce the anticoagulant effect of warfarin (monitor INR); additive blood-pressure lowering with antihypertensives | |
| Magnesium (elemental) | Dosing: 9 mg/kg/day elemental magnesium PO, divided 3 times daily | GI upset, diarrhea | May decrease absorption of bisphosphonates or tetracycline/quinolone antibiotics -- separate administration by at least 2 hours | Refers to a general elemental-magnesium nutritional supplement (e.g., glycinate, citrate, or oxide salt) -- not the magnesium-salt laxative or antacid products elsewhere in this Drug Database, which are formulated and dosed differently. Magnesium citrate may have better absorption/tolerability than other salts. |
| Melatonin | Weight under 40 kg: 1-4 mg PO HS Weight over 40 kg: 2-8 mg PO HS | Daytime sleepiness, nightmares | Additive sedation with alcohol/CNS depressants; may lower efficacy of dihydropyridine calcium channel blockers; fluvoxamine may increase melatonin levels | For migraine prevention, a standard immediate-release, NPN-licensed melatonin supplement is used -- distinct from the specific extended-release prescription product referenced on this Drug Database page. |
| Riboflavin (vitamin B2) | Weight 20-40 kg: 100 mg PO BID Weight over 40 kg: 200 mg PO BID | Harmless bright yellow-orange urine discolouration; occasional mild GI upset | None significant |
References
- The International Classification of Headache Disorders, 3rd edition — Cephalalgia, Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1-211
- Practice guideline update summary: Acute treatment of migraine in children and adolescents — Neurology, American Academy of Neurology and American Headache Society (Oskoui M, Pringsheim T, Holler-Managan Y, et al.). Neurology 2019;93(11):487-499
- Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list — Neurology (Do TP, Remmers A, Schytz HW, et al.). Neurology 2019;92(3):134-144
- PedMIDAS: development of a questionnaire to assess disability of migraines in children — Neurology (Hershey AD, Powers SW, Vockell ALB, et al.). Neurology 2001;57(11):2034-2039
- Headache: neuroimaging recommendation — Choosing Wisely Canada, Canadian Headache Society. Choosing Wisely Canada, accessed 2026
- Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention — Neurology, American Academy of Neurology and American Headache Society (Oskoui M, Pringsheim T, Billinghurst L, et al.). Neurology 2019;93(11):500-509
- Pharmacological management of acute migraine attacks in children and adolescents presenting to the emergency department — Canadian Paediatric Society, Acute Care Committee (Rogers S, Orr SL, Parisien B, Chauvin-Kimoff L). Canadian Paediatric Society Position Statement, December 2025
- Trial of amitriptyline, topiramate, and placebo for pediatric migraine — New England Journal of Medicine (Powers SW, Coffey CS, Chamberlin LA, et al., CHAMP Investigators). N Engl J Med 2017;376(2):115-124
- AJOVY (fremanezumab) Product Monograph -- pediatric episodic migraine prevention indication — Health Canada / Teva Canada Innovation. Product Monograph, pediatric indication approved February 2026
Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.