Headache and migraine in children: Case

This girl has chronic migraine complicated by medication-overuse headache. Her headache pattern meets the ICHD-3 definition of chronic migraine, which is 15 or more headache days a month for over three months with at least eight migrainous days, and her attacks are bilateral, throbbing, and accompanied by nausea and photophobia, with a family history of migraine in her mother. Her daily use of ibuprofen and a combination paracetamol and codeine tablet over the last two months meets the threshold for medication-overuse headache, which is acute medication on 15 or more days a month for simple analgesics, or 10 or more days a month for combination analgesics, sustained for over three months. Her normal fundi, blood pressure, and neurological examination, and the absence of any red flag, confirm that this is a primary headache disorder rather than a secondary cause, so imaging is not indicated. [1]

Confirming the diagnosis and excluding a secondary cause

The first task is to confirm that this is a primary headache and to exclude a secondary cause. The history meets the ICHD-3 criteria for chronic migraine, and the deliberate red-flag screen is negative: there is no thunderclap onset, no occipital location, no focal deficit, no papilloedema, no early-morning vomiting, no progressive or under-five pattern, and no systemic features. Her blood pressure is normal, her fundi show no papilloedema, and her full neurological examination including gait and coordination is normal. On these grounds I would not arrange neuroimaging, because a primary headache that meets the criteria, with a negative red-flag screen and a normal examination, does not need a scan. The disability is substantial: she has missed three weeks of school, withdrawn from sport, and describes low mood, which I would quantify with the PedMIDAS to guide the intensity of the preventive plan. [1]

Reversing the medication-overuse headache

The single most effective and most reversible intervention is to stop the daily analgesia. The combination paracetamol and codeine tablet must be discontinued immediately, because codeine has no place in paediatric migraine and the daily combination analgesia is driving the chronification of her headaches. I would wean the ibuprofen to a strict maximum of two to three days a week, used only for the more severe attacks and taken early. I would warn the family that the headaches may transiently worsen during the wean and that this is expected, and I would set a clear analgesic ceiling in writing. No preventive drug works while daily analgesia continues, so the wean is the foundation of the plan, not an optional extra. [12]

The acute and stepped preventive plan

The acute plan is ibuprofen 10 mg per kg taken early in an attack, with sumatriptan nasal spray 10 to 20 mg for the moderate-to-severe attacks, and an antiemetic for nausea. The 2016 Cochrane review found ibuprofen and paracetamol the best-supported acute agents, and the triptans are reserved for attacks that do not respond to simple analgesia, capped at two to three days a week. [8]

The preventive plan is built in a stepped sequence. The foundation is lifestyle medicine: regular sleep, adequate hydration, meals that are not skipped, daily exercise, and trigger recognition, supported by a headache and analgesic diary. The most effective single addition for a girl with chronic migraine and low mood is cognitive behavioural therapy, which the Powers trial showed roughly halved headache days and disability when added to a preventive drug compared with headache education. I would refer her to a paediatric headache service or a psychologist trained in cognitive behavioural therapy for migraine. [7]

If her attacks remained disabling despite the wean, the lifestyle platform, and cognitive behavioural therapy, I would consider a preventive drug and I would frame the conversation around the CHAMP trial. The CHAMP trial found that neither amitriptyline nor topiramate was superior to placebo for paediatric migraine, because the placebo response reaches up to 60 per cent, and the 2019 AAN and AHS guideline therefore frames these drugs as options to consider rather than established preventives. If I started a drug, I would use amitriptyline at night or topiramate titrated to a weight-based target, counsel the family on the high placebo response and the uncertain drug benefit, and judge the response over eight to twelve weeks before continuing, switching, or weaning. [6]

Prognosis and follow-up

The prognosis for this girl is good but depends on reversing the medication overuse and building the behavioural plan. I would review her in clinic at four to six weeks with a headache and analgesic diary and a repeat PedMIDAS to track the response to the wean and the lifestyle and cognitive behavioural interventions. I would address her low mood, her school absence, and the family's understanding that the goal is a return to function and school attendance rather than a headache-free state. I would counsel that relapses during stress, sleep disruption, and examination periods are expected and manageable, and that the combination of an analgesic wean, a structured lifestyle platform, and cognitive behavioural therapy is the evidence-based path back to an episodic pattern and a return to school and sport. [7] [12]