Review Evaluates Triggers of Pediatric Migraine

Researchers assessed 3 risk factors for migraine in children and adolescents: stress, sleep poverty, and alimentation.

To devise a plan for disseminating optimal pediatric headache education, researchers assessed 3 risk factors for migraine in children and adolescents: stress, sleep poverty, and alimentation (including diet and obesity).

Although findings from the narrative literature review led the authors to conclude there is not enough evidence to establish a headache education plan regarding behavioral and lifestyle interventions in this population, they noted that “clinicians should advise patients to avoid certain triggers, such as stress and sleep disorders, and make a few conservative dietary changes.”

The estimated mean prevalence of headache is around 50% in the pediatric population, and the overall mean prevalence of migraine is 9.1%. Roughly half of children suffering from migraine also manifest the condition in adulthood. Early diagnosis and multidisciplinary interventions comprising both pharmacologic and nonpharmacologic approaches can improve long-term migraine outcomes.

Reports showing evidence in favor of cognitive-behavioral therapy (CBT) among adult migraineurs have prompted some researchers to argue that CBT ought to be first-line treatment among pediatric populations. However, CBT can be costly and time consuming and may only benefit older children capable of metacognition.

“Although the current treatment guidelines focus on behavioral and lifestyle interventions to correct the factors commonly associated with migraine (negative emotional states, obesity and high body weight, infrequent exercise, and lack of sleep), the focus on dispensing headache and migraine education is inadequate, making this an area that requires extensive research,” the review authors wrote. “Without quality evidence on how proper headache education can improve outcomes, preventing migraines will remain challenging for many children and adolescents.”

Investigators compiled randomized controlled trials, systematic reviews, observational studies and other studies found in the PubMed database that were published through June 2020 with no date limits.

Among the trigger factors documented in the studies, stress was found to be the most problematic and common trigger for pediatric migraineurs. Brain structure can become disrupted by stress as a result of multifactorial and epigenetic processes that alter gene expression. Furthermore, “if registered biologically during the early developmental stages, stress can lead to physiological changes that may increase a child’s susceptibility to other stress-related behavioral disorders, such as depression and anxiety, later in life,” the researchers explained.

Psychiatric disorders, or mood/anxiety disorders, were also commonly reported among pediatric migraineurs. Psychiatric conditions may be comorbid with migraine. However, “behavioral comorbidities have not been observed in the majority of pediatric migraine patients,” the authors wrote, while “currently available screening tools make it difficult to distinguish between the characteristics of migraine and those of psychiatric illness.”

One study found the presence of family-level stressors early in life was associated with a higher likelihood of adolescent migraine and increased symptoms of depression and anxiety in late childhood. Because of this association, the authors argued that psychiatric comorbidities should be addressed in a timely manner to prevent future development of migraines. Additional studies highlighted the strong association between adverse childhood experiences, like child abuse, and recurrent migraines in adulthood.

When it comes to sleep, study findings have shown that migraine might be a result of underlying sleep disorders or could trigger further sleep disturbances. Regardless, improving sleep quality can decrease the occurrence of migraine. “Conventional clinical wisdom, sleep assessment, and adjustment in sleep habits will always be recommended for children suffering from migraines, in addition to which structured sleep hygiene rules can improve both headaches and sleep in the long run,” the authors wrote.

In addition, dietary triggers may affect different stages of the migraine process. Certain foods could influence the release of serotonin and norepinephrine, which could cause vasoconstriction or vasodilation, or could stimulate the trigeminal ganglia, brain stem, and cortical neuronal pathways. But because multiple triggers and variables can modify the pain threshold in an individual, and this factor is usually neglected in favor of a preventive drug therapy, evaluating the role of diet in pediatric migraineurs is complex.

“It is imperative to counsel patients and their parents/caretakers to avoid fasting or skipping meals and encourage a well-balanced diet, along with educating them on good practices to avoid obvious triggers,” the authors wrote. Instead of trying to eliminate uncertain migraine triggers, evidence suggests that maintaining a healthy weight may be more effective in treating migraine.

Following a healthy lifestyle in addition to overall management of sleep, stress, and diet are essential for pediatric migraineurs’ health, the researchers concluded. “Future larger, prospective studies are needed to design a standardized educational and cognitive treatment manual that will contribute to the development of pediatric migraine treatment.”


Yamanaka G, Morichi S, Suzuki S, et al. A review on the triggers of pediatric migraine with the aim of improving headache education. J Clin Med. Published online November 19, 2020. doi:10.3390/jcm9113717