Migraine in a child or teenager: how to recognise it and what parents can do

“His head hurts again. And again on a Monday.”

His mother said it half under her breath, as if afraid her son might hear. The eleven-year-old was lying in a darkened room, pale, with a bucket by the bed. Two hours earlier he had been sick. In the evening he would get up as if nothing had happened, eat dinner and play football in the yard. And that was exactly what puzzled her: how can he look so ill in the morning and be perfectly well in the evening? Could it be that he just doesn’t feel like going to school?

Many parents ask themselves this. And it’s understandable — a child’s pain can’t be seen, it comes and goes, and sometimes it coincides with the very days the child doesn’t like. But for many of these children it is migraine, which in children often looks different from migraine in adults and is therefore easy to miss. This post is for parents: how to recognise it, where to go first and what the family can do.

Migraine is an illness, in children too

Let’s start with the most important thing. Migraine is a neurological disease — not a psychosomatic symptom and not a way for a child to avoid obligations. It has its own biology and its own diagnostic criteria, and it can appear in childhood — in some children even before they start school. The diagnosis is made by a doctor, and treatment is chosen by a doctor. I won’t be giving any advice about medication in this post.

Migraine in children is not rare. A review of population studies on headache in children and adolescents found that on average around 7.7 per cent of children and adolescents have migraine — so probably at least one or two in every class. Before puberty, boys and girls are affected roughly equally often; after puberty, migraine becomes more common in girls, a pattern that then continues into adulthood.

Why do I stress that it is an illness? Because a great deal depends on how parents understand their child’s pain. If migraine is an “excuse”, the child hears that they are not believed. If it is an illness, the child hears that their experience is real — and that is the foundation for everything that follows.

How it looks different from migraine in adults

One of the biggest obstacles to recognising it is that children don’t describe migraine the way adults do, and they also experience it somewhat differently. The international classification of headache disorders takes this into account:

• Attacks can be shorter. In adults they last from four hours to three days; in children they can last from as little as two hours.
• The pain is often on both sides — across the forehead or temples; one-sided pain more often appears only in the teenage years.
• The child is pale, has dark rings under the eyes, feels sick or vomits.
• They can’t tolerate light and sound, which a younger child shows through behaviour: closing their eyes, hiding under the duvet, switching off the television.
• Sleep often ends the attack. The child falls asleep and wakes up pain-free. This is exactly what often confuses parents.

Younger children often can’t describe pain. Instead of “my head hurts” they say “I feel sick”, “my tummy hurts” or nothing at all — they simply stop playing and lie down. Some children also have episodes that the classification lists among syndromes associated with migraine: recurring abdominal pain with no other cause, recurring vomiting or short episodes of dizziness. Only a doctor can judge whether that’s what is going on — I mention them so that you know they’re worth bringing up at the appointment.

That last point in the infographic is the most important one for parents. The fact that the child is fine again in the evening is not proof that they weren’t ill in the morning. That is how migraine works — the attack passes, and between attacks the person is well. Adults with migraine know this; a child doesn’t yet have the words to explain it.

The first step is the paediatrician

If your child keeps complaining of headaches, the first step is a visit to your child’s paediatrician. They will examine the child, rule out other causes and, if needed, refer them to a specialist, usually a paediatric neurologist. Don’t wait for it to “just pass”, and don’t try to work out on your own whether it’s migraine — not least because in children it is important to rule out other causes of headache.

The appointment will be more useful if you come prepared. For a few weeks beforehand, write down: when the headache started, how long it lasted, what the child was doing before, whether they vomited, whether they were pale, whether sleep helped. An older child can keep the notes themselves. I describe how to keep such a record in A migraine diary — most of the advice applies to children too, except that with younger ones you do the writing.

There are also signs, however, when it isn’t time for notes. Call 112 straight away or go to A&E if the headache is sudden and very severe, if it comes with fever and a stiff neck, confusion, weakness, difficulty speaking or walking, or if it appears after a blow to the head. See a doctor as soon as possible, too, if the headache wakes the child from sleep, if it comes with morning vomiting, or if the headaches get worse from week to week. More on how migraine differs from other headaches is in Migraine is not just a bad headache: what the difference is and why it matters.

“Could it be he just doesn’t want to go to school?”

Let’s go back to the question from the beginning. Parents don’t ask it out of indifference but because it really is hard to tell. Headaches do often appear on a Monday or before a test. Does that mean the child is making them up?

Not necessarily. For some people with migraine, attacks are linked to tension, irregular sleep or skipped meals — and all of these are more common during the school week than during the holidays. A Monday after a weekend with a different sleep rhythm really is riskier for some children. So the fact that an attack coincides with a stressful day doesn’t mean it isn’t real.

At the same time, migraine and anxiety often go together in children. A child who is afraid of school can feel real physical symptoms too — tummy ache, nausea, headache. How to recognise when school itself is behind it is covered in the knowledge base under school anxiety, and more broadly in Anxiety in children. What matters is that you don’t have to choose between “they’re ill” and “they’re pretending”. It may be migraine made worse by stress. It may be anxiety showing itself through the body. It may be both. Telling them apart is the job of a doctor and, where needed, a psychologist or psychotherapist — not a parental investigation.

What happens in the family when a child is in pain

Recurring pain doesn’t affect only the child but the whole family. In relational family therapy, in which I am training, we always look at a child’s difficulty as something that also happens between people — not because the family caused it, but because we all respond to it and in doing so shape how the child experiences it.

Research on children with recurring pain shows that parents’ responses play an important role in how much the pain gets in the way of the child’s everyday life. Parents usually respond in one of two ways, both out of love:

• Overprotection. With every headache the child stays home, skips training, and the parents keep asking how they are. In the short term this is a relief. In the long term the child’s life can shrink, and the pain becomes the centre of the family.
• Brushing it off. “It’s not that bad, go to school.” The child learns that it isn’t safe to talk about pain and starts hiding it — or, on the contrary, shows it even more loudly.

Most parents swing between the two. In the morning they are patient; on the third Monday in a row their strength runs out. That’s human. But it helps if the two of you as parents agree on a shared approach, so the child doesn’t get a different message from each of you. And don’t forget the siblings, who sometimes quietly watch all the attention turn to the brother or sister with the headache.

If you notice that each of your child’s headaches frightens you so much that in your mind you’re already at the worst possible diseases, that is worth looking at too. Parental worry is natural, but when it becomes a constant readiness for catastrophe, the child senses it. This is the subject of Health anxiety.

When a parent and a teenager talk about it

With teenagers the conversation changes. They don’t want their parents monitoring them, yet migraine often takes away exactly what matters most to them — parties, matches, time with friends. Here is how such a conversation might sound (composite, not a real person):

“That’s the third time this month you’ve missed training. Maybe you should spend less time on your phone.”
“You always think it’s my own fault.”
“I don’t think that. I’m worried.”
“Then ask me how it is. Don’t tell me what I’m doing wrong.”
“All right. How was today?”
“Awful. In maths I could only see half the board and I was scared I’d be sick in front of everyone.”

The teenager says something important here. When a parent starts with a cause (“too much phone”), the child hears an accusation. When a parent starts with a question, the child says what is really weighing on them — in this case, the fear of being embarrassed in front of classmates. For teenagers, this fear is often a bigger burden than the pain itself. How teenagers deal with it is closely linked to how they see themselves — see Self-image in the teenage years.

With teenagers, keep an eye on mood as well. Migraine and depression often appear together, and withdrawal, tiredness or a loss of enjoyment aren’t always just the result of headaches. How to tell ordinary teenage ups and downs from depression is covered in Teenage depression. If your child talks about not wanting to live any more, call the Samaritan helpline on 116 123 or the mental health crisis line on 01 520 99 00 (7 pm to 7 am) in Slovenia, and in an emergency 112.

What can help alongside the doctor

Treating migraine is a doctor’s job. Alongside that, though, psychological approaches for children and adolescents with headache are well supported by research. A Cochrane review of psychological therapies for recurring pain in children found that they can reduce pain in headache. In an American study of children and adolescents with chronic migraine, those who received cognitive behavioural therapy in addition to medical treatment had a greater reduction in headache days than those who received headache education only.

What does this mean in practice? A child can learn:

• relaxation techniques, such as breathing with a longer out-breath or progressive muscle relaxation — children often pick them up faster than adults,
• to recognise the early signs of an attack, so they can tell an adult in time,
• to handle the fear of the next attack and the worry about what classmates will think,
• a regular rhythm of sleep, meals and drinking, which is protective for many people with migraine.

Psychological work doesn’t mean migraine is “in the head” in the sense of being imagined. It means the child gets tools with which they can influence part of what happens around the illness. For a child who feels helpless in the face of attacks, that experience alone matters.

Exercise: a family plan for an attack

You can do this exercise together this week, at a calm moment — not during an attack. With a younger child you lead it; with a teenager you do it as equals.

1. Ask your child how they know an attack is coming. What do they feel first? Perhaps pallor, tiredness, yawning, changes in vision. Write it down in their own words.
2. Agree on a signal. One sentence or word the child uses to say it’s starting — at home and at school. “It’s starting” is enough.
3. Write down what helps then. A dark room, a glass of water, quiet, whatever the doctor has advised. And what doesn’t help — for example, being asked questions every five minutes.
4. Agree what happens after the attack. When the child returns to their obligations, how they catch up on what they missed. The aim is for life to carry on as soon as possible, without pushing the child.
5. Show the plan to the paediatrician and, if your child agrees, to their class teacher. That way all the adults act the same way and the child doesn’t have to explain it again each time.

The plan tells the child two things: that you believe them, and that the illness is not the centre of their life. Both matter equally for a child with migraine.

Where my argument doesn’t hold

This whole post revolves around migraine. But I want to be clear about its limits.

Not every headache a child has is migraine. Children get headaches with a cold, poor sleep, too little fluid, vision problems or tension. And sometimes a headache is a sign of an illness a doctor needs to recognise as soon as possible. That is why the first step is always the paediatrician, not a post online.

A family perspective doesn’t mean the family is to blame. When I talk about parents’ responses, I am not saying they cause migraine. Migraine has a biological basis and often runs in families partly because of heredity. A family can influence how a child lives with the illness — not whether they have it.

Sometimes the problem at school is real and separate. If headaches come together with withdrawal, sleepless nights before school or stories about classmates, there may be something behind it that needs attention in its own right — bullying, learning difficulties or relationships in the class. Migraine neither rules this out nor explains it.

Psychotherapy is not instead of a doctor. It can come alongside, once there is a diagnosis, and help with fear, distress and relationships in the family. I also work with English-speaking families, in person in Ljubljana.

What to remember

• Migraine is a neurological disease that can appear in childhood. It isn’t an excuse and it isn’t pretending.
• In children it is often shorter and on both sides, with pallor and nausea, and sleep often ends the attack.
• The first step is the paediatrician. Prepare notes on the headaches; with a sudden very severe headache, fever with a stiff neck or neurological signs, call 112 at once.
• Parents’ responses affect how much the illness gets in the child’s way — what helps is believing them while keeping everyday life going.
• Relaxation techniques and cognitive behavioural approaches are a well-supported complement to medical treatment.