OCCASIONAL REVIEW
The migraine syndrome in
children
Rachel Howells
Ishaq Abu-Arafeh
Abstract
Migraine is a brain disorder with complex pathogenesis and aetiology.
The clinical presentation of migraine changes with brain maturation
during the first 20 years of life. Migraine is typically a paroxysmal dis-
order with well-defined episodes separated by freedom of symptoms.
Despite the variable clinical features of migraine, each episode may
have a predictable sequence of phases. The main phase of each
episode is characterized by one or more symptoms of severe head-
ache, vomiting, abdominal pain, vertigo and/or torticollis. This phase
may be preceded by premonitory and aura symptoms, and followed
by a recovery phase and resolution of symptoms. These phases can
be clear and well defined in some patients but indistinct and subtle
in others. Different migraine presentations share common trigger fac-
tors, associated symptoms, relieving factors and family history. This
review describes migraine as a primary headache disorder, but with
greater emphasis on other forms of migraine in children and young
people including abdominal migraine (AM), cyclical vomiting syndrome
(CVS), benign paroxysmal vertigo (BPV), benign paroxysmal torticollis
(BPT) and infantile colic (IC). We will discuss clinical assessment, diag-
nostic criteria, investigation (when needed) and treatment for each
childhood migraine syndrome.
Keywords abdominal migraine; cyclical vomiting syndrome; infantile
colic; migraine; torticollis; vertigo
Introduction
The classification and definition of paroxysmal childhood disor-
ders have evolved over the past 100 years. For a long time,
abdominal migraine (AM), cyclical vomiting syndrome (CVS),
benign paroxysmal vertigo (BPV), benign paroxysmal torticollis
(BPT) and infantile colic (IC) were considered functional, idio-
pathic or non-specific in nature. Over 30 years between 1988 and
2018, the 3 editions of International Classification of Headache
Disorders have progressively integrated these disorders into the
migraine classification.1 The Rome Foundation has included
abdominal migraine, cyclical vomiting syndrome, and infantile
colic in the taxonomy of functional gastrointestinal disorders.2 The
evidence for the inclusion of AM, CVS, BPT, BPV and IC under the
Rachel Howells MA MBBChir MRCPCH Dip Med Ed, Consultant
Paediatrician in Acute Paediatrics and Paediatric Neurology, Royal
Devon and Exeter Hospital NHS Foundations Trust, Exeter, UK.
Conflicts of interest: none declared.
Ishaq Abu-Arafeh MBBS DM MRCP FRCPCH, Consultant in Paediatrics
and Paediatric Neurology, Paediatric Neurosciences Unit, Royal
Hospital for Children, Glasgow, UK. Conflicts of interest: none
declared.
PAEDIATRICS AND CHILD HEALTH 32:10
umbrella of migraine has become more compelling over the past
decade.3 Their recognition as migraine disorders not only brings
clarity to their aetiology, pathogenesis and classification, but,
more importantly, will help achieve more accurate clinical asses-
sment, diagnosis and prediction of prognosis, and ultimately the
better management of patients.
Clinical features of the migraine syndrome in children
Migraine headache is a common disorder with a prevalence of
around 8% in children and adolescents. Young boys and girls
under the age of 14 years are equally affected, but in adolescents
older than 14 years, girls are at least 1.5 times more likely to be
affected than boys. Migraine is sub-classified by the widely
accepted criteria of ICHD 3 into several disorders (Box 1). Disor-
ders classified as “complications of migraine” are more likely to be
seen in adult patients. Disorders listed under “episodic syndromes
that may be related to migraine” mainly affect children and ado-
lescents and constitute the main subjects of this review.
Migraine without aura is the most common form of migraine in
children and adolescents. Episodes of migraine usually last 2e72
hours. During recurrent episodes, headache is the most prominent
symptom. Children and young people usually use their own words
such as ‘sharp’ or ‘banging’ to describe throbbing pain which is of
moderate to severe intensity. At its peak, the pain stops or prohibits
normal activities and makes the child or adolescent seek some-
where dark and quiet to rest or sleep. Headache is often associated
with refusal to eat, nausea, vomiting and intolerance to light, noise
and smell. Premonitory symptoms of yawning, craving for food,
heightened perception and mood change precede headache onset,
sometimes by days. A recovery period of fatigue usually follows
headache.
Abbreviated ICHD 3 (2018) classification of migraine
disorders1
1. Migraine without aura
2. Migraine with aura
2.1 Migraine with typical aura
2.2 Migraine with brainstem aura
2.3 Hemiplegic migraine (HM)
2.3.1 Familial HM
2.3.2 Sporadic HM
2.4 Retinal migraine
3. Chronic migraine
4. Complication of migraine
5. Probable migraine
5.1 Probable migraine without aura
5.2 Probable migraine with aura
6. Episodic syndromes that may be associated with migraine
6.1 Cyclical vomiting syndrome
6.2 Abdominal migraine
6.3 Benign paroxysmal vertigo
7. Benign paroxysmal torticollis
Box 1
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 OCCASIONAL REVIEW
Investigations are only necessary if the clinical presentation is
either atypical, accompanied by headache ‘red flags’ indicating a
secondary cause is possible, or if thorough clinical assessment
cannot exclude underlying disorders.
Migraine with aura is less common than migraine without aura,
affecting only 1 in 4 children and young people with migraine. It
has similar characteristics to migraine without aura but with
added aura symptoms before or with the headache. Visual dis-
turbances are the most common aura symptoms, followed by
sensory disturbances, speech disorder and motor weakness.
Typical aura symptoms usually evolve over at least 5 minutes
and are followed within 60 minutes by the headache phase.
Migraine is described as chronic migraine when headaches
occur on at least 15 days per month for at least three consecutive
months, with headaches consistent with migraine on at least
eight days per month. Chronic migraine affects 1e2% of ado-
lescents. Girls are slightly more likely to be affected than boys.
Chronic migraine is associated with poor response to treatment,
high impact on quality of life, school attendance, academic
achievement and participation in sports and leisure activities.
Chronic migraine may be compounded by medication overuse.
Infantile colic (IC)
Most paediatricians are familiar with this common disorder,
distressing infants and their carers alike. It is characterized by
episodes of relentless crying in infants less than three months of
age, lasting for several hours per day (often late in the day or
evening) on at least three days a week for longer than three
weeks. It affects 10e15% of infants, boys and girls equally. The
condition usually peaks at six weeks and decreases by 4e5 mon-
ths of age.
The aetiology and pathogenesis of infant colic are not known.
Several factors and mechanisms have been proposed, including
infant factors such as sleep disruption, visceral hypersensitivity,
allergy, gut microflora and dysmotility. Breast-fed infants are less
likely to suffer from colic. Maternal factors implicated in infantile
colic include psychological stress, poor physical health and
smoking during pregnancy, and negative childbirth experiences.
The characteristic clinical features of IC are the episodic nature
of inconsolable crying and distress with complete resolution be-
tween episodes. Infants with colic enjoy normal growth, weight
gain and development. Investigations reveal no other cause for the
distress. The source of distress is not clear but is assumed to be
abdominal pain. Babies often have their eyes closed, look pale and,
Criteria for the diagnosis of infantile colic
Rome IV (2016)2
1. An infant who is less than five months of age when the symptoms
start and stop
2. Recurrent and prolonged periods of infant crying, fussing, or irri-
tability reported by caregivers that occur without obvious cause
and cannot be prevented or resolved by caregivers
3. No evidence of infant failure to thrive, fever, or illness
Table 1
PAEDIATRICS AND CHILD HEALTH 32:10
unlike other types of pain, are not comforted by being cuddled.
These features resemble photophobia, vasomotor changes and
allodynia seen in migraine.
Criteria for diagnosis of IC are listed in the ICHD 3 in the ‘ap-
pendix’ section, denoting that sufficient evidence for its inclusion
in the main body has not been confirmed. Criteria for diagnosis of
IC outlined within the ICHD 3 and Rome IV consensus are largely
similar. Rome IV has excluded the rule of 3 hours, days and weeks
for use in clinical practice. These have been retained in ICHD for
the purpose of clinical research (Table 1).
Evidence to support the close relationship between IC and
migraine is demonstrated from epidemiological and follow up
studies of babies with IC. Prospective studies on infants with
colic show that they are twice as likely to develop migraine in
later childhood. Children with migraine are more likely than not
to have had infantile colic symptoms e one study suggested 79%
compared with a population incidence of 17%. Mothers with
migraine are more than twice as likely to have offspring with
infantile colic compared with mothers without migraine.
The UK National Institute of Health and Clinical Excellence
recommends soothing strategies such as gentle motion, holding/
swaddling and white noise. NICE also encourages parents/carers
to look after their own well-being. Neither NICE nor other sys-
tematic reviews support hydrolysed formulas, probiotic use,
simethicone, lactase drops or herbal remedies since the studies
investigating these are small and/or prone to bias. Treatment
with simple analgesics such as paracetamol can relieve pain, but
acute migraine treatments such as sumatriptan have not been
trialled, and their pharmacological properties in infants have not
been studied. As such, these cannot be recommended.
Benign paroxysmal torticollis (BPT)
BPT is a disorder of the childhood migraine syndrome with a
median age of onset of 2e3 years. BPT is considered rare but its
true prevalence may be higher due to underdiagnosis and lack of
awareness of the condition. In some studies 1% of children with
migraine have a history of BPT. BPT causes anxiety due to the
nature of the cardinal symptom of unexplained head tilt. Epi-
sodes of torticollis last for minutes to days and are often asso-
ciated with distress, pallor, refusal to eat, vomiting, irritability or
lethargy, ataxia and occasionally, hypotonia. Older children often
report headaches during episodes.
Episodes of torticollis resolve spontaneously with complete re-
covery between episodes. Episodes recur every few weeks and
reduce in frequency over 2e3 years until they stop by the age of 5
ICHD 3 (2018)1
A. Recurrent episodes of irritability, fussing or crying from birth to four
months of age, fulfilling criterion B
B. Both of the following:
1. episodes last for  3 hours/day
2. episodes occur on  3 days/week for  3 weeks
C. Not attributed to another disorder.
389 Ó 2022 Elsevier Ltd. All rights reserved.
 OCCASIONAL REVIEW
years in most patients. Early motor developmental delay, if present,
seems to be transient, and the prognosis for neurodevelopment is
generally favourable.
The aetiology and pathogenesis of BPT are not well under-
stood. Around half of children with BPT have a family history of
migraine and/or IC. There are case reports of families with BPT,
migraine and hemiplegic migraine associated with CACN1A and
PRRT2 channelopathies. Follow up studies showed children with
BPT are more likely than unaffected children to develop benign
paroxysmal vertigo of childhood (45e51%), cyclical vomiting
syndrome (9%) or migraine (as high as 63%) later in childhood.
Torticollis can also occur as a feature of IVth cranial nerve palsy
(head tilted to the side of the lesion), posterior fossa (cer-
ebellopontine) mass lesion, cervical cord lesion (a tumour or
Chiari malformation) or dystonia. Sternocleidomastoid shortening
as a result of birth injury is a common cause of fixed torticollis.
The diagnosis of BPT is made on the application of the clinical
criteria (Box 2) and exclusion of these other possible causes. The
episodic nature of torticollis in BPT, alternation of the affected side,
association with complete recovery and normal neurological ex-
amination in-between episodes help to exclude other causes.
Videos of the attacks can help to secure the diagnosis. MRI of the
brain and cervical spine, ictal EEG and ophthalmological assess-
ment may be required where the diagnosis is uncertain.
The management of children with BPT is generally symp-
tomatic and supportive. Vomiting, ataxia and irritability appear
to respond to simple analgesia and antiemetics such as
ondansetron and prochlorperazine. There are case reports of
response to migraine prophylactic agents such as cyprohepta-
dine, topiramate and riboflavin, but no high-quality drug trials to
determine efficacy have been conducted. Multi-centre clinical
trials are needed if adequate treatment is to be proven.
Benign paroxysmal vertigo (BPV)
BPV is characterized by episodes of sudden fearfulness, unstead-
iness and reluctance to stand up or walk. During an episode of BPV,
the child holds on to furniture or their carer’s legs, or simply lies
down on the floor. The child looks pale, feels sick and occasionally
vomits. An observant parent or clinician may note horizontal
nystagmus. In younger children, vertigo is inferred from their
behaviour. Older children may describe unsteadiness or a feeling
of a spinning of the room around them. The child does not lose
ICHD 3 (2018) criteria for the diagnosis of BPT1
A. Recurrent attacks in a young child, fulfilling criteria B and C
B. Tilt of the head to either side, with or without slight rotation,
remitting spontaneously after minutes to days
C. At least one of the following five associated symptoms or signs:
1. pallor
2. irritability
3. malaise
4. vomiting
5. ataxia
D. Normal neurological examination between attacks
E. Not attributed to another disorder.
Box 2
PAEDIATRICS AND CHILD HEALTH 32:10
consciousness, and there are no abnormal movements or
posturing to suggest an epileptic event. Between episodes, the
child returns to their normal self, and the neurological examination
is normal.
BPV is the most common cause of episodic dizziness in chil-
dren presenting to paediatricians, paediatric neurologists and
ear, nose and throat specialists. The prevalence of BPV is esti-
mated at 2e3% of the childhood population and is slightly more
common in girls. The typical age of onset is 3e4 years but may
range from 18 months to 12 years. Between 21 and 33% of
children with BPV are reported to have migraine headaches or a
combination of migraine and cyclical vomiting in later childhood
and adolescence. Some will develop ‘vestibular migraine’: at-
tacks of disabling vertigo lasting between 5 minutes and 72h
associated with throbbing headache and its typical associated
features. Others will have additional symptoms supporting a
diagnosis of migraine with brainstem aura. Migraineurs in later
childhood are more likely (9%) than would be expected by
chance to have had BPV in earlier life.
The diagnosis of BPV can be made clinically by applying the
ICHD 3 criteria for diagnosis (Box 3). A video recording of an
episode can help, where the diagnosis is uncertain from the
history. Other causes of dizziness should be considered,
including central (traumatic brain injury or structural brain ab-
normalities) and peripheral (recurrent otitis media, Meniere’s
disease) causes, as well as emotional and mental health diffi-
culties. Investigations are only required if other causes are sus-
pected. Brain imaging will be needed if the child has persistent
non-resolving symptoms, new neurological deficit, squint or
seizures. Standard and ambulatory electroencephalography
(EEG) is needed if the child’s episodes have features of epileptic
seizures. Inner ear disease should be suspected if symptoms are
associated with hearing loss and/or tinnitus. Routine vestibular
function tests can be practically challenging in young children,
are not usually required to confirm the diagnosis.
Due to its name and acronym, BPV can be confused with benign
paroxysmal positional vertigo (BPPV), from which it is aetiologi-
cally and clinically distinct. BPPV is seen almost exclusively in
ICHD-3 (2018) criteria for the diagnosis of BPV1
A. At least five attacks fulfilling criteria B and C
B. Vertigo* occurring without warning, maximal at onset and
resolving spontaneously after minutes to hours without loss of
consciousness
C. At least one of the following five associated symptoms or signs:
1. nystagmus
2. ataxia
3. vomiting
4. pallor
5. fearfulness
D. Normal neurological examination and audiometric and vestibular
functions between attacks
E. Not attributed to another disorder**.
*Infer vertigo from behaviour **Exclude posterior fossa tumours,
seizures and other ENT disorders.
Box 3
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 OCCASIONAL REVIEW

Criteria for the diagnosis of AM

ICHD 3 (2018) criteria for the diagnosis of AM1 Rome IV (2016) criteria for the diagnosis of AM2

A. At least five attacks of abdominal pain, fulfilling criteria BeD At least 2 attacks over 6 months must include all the following:
B. Pain has at least two of the following three characteristics: 1. Paroxysmal episodes of intense acute periumbilical pain, midline or
1. midline location, periumbilical or poorly localized diffuse abdominal pain lasting 1 hour or more
2. dull or ‘just sore’ quality 2. Episodes are separated from weeks or months
3. moderate or severe intensity 3. The pain is incapacitating interferes with normal activities
C. At least two of the following four associated symptoms or signs: 4. Stereotypical pattern and symptoms in individual patient
1. anorexia 5. The pain is associated with 2 or more of the following:
2. nausea a. Anorexia
3. vomiting b. Nausea
4. pallor c. Vomiting
D. Attacks last 2e72 hours when untreated or unsuccessfully treated d. Headache
E. Complete freedom from symptoms between attacks e. Pallor
F. Not attributed to another disorder 6. After appropriate evaluation, the symptoms cannot be fully
explained by another medical condition

Table 2

adults, caused by cupulolithiasis and triggered by movement, Abdominal migraine (AM)

often turning in or rising from bed.
This is a migraine disorder of mid-childhood with a peak inci-
Management of BPV centres around giving a full explanation
dence of five to nine years, occurring in 1e4% of school-aged
of the syndrome and its relationship to migraine. It is important
children. It is slightly more common in girls. Pain is either per-
to reassure parents that the events are not harmful, though un-
iumbilical or poorly localized, dull, moderate-severe in intensity,
pleasant. Medical treatment is not usually necessary, but if the
lasting from as little as an hour to several days. Pain is associated
episodes are prolonged, causing disruption to the child’s nursery
with at least one other symptom, including pallor, anorexia,
or school attendance and affecting family life, treatment with
nausea or vomiting. Headaches co-occur with abdominal
anti-migraine preventive medications (pizotifen or flunarizine)
migraine attacks in some patients. Attacks are interspersed by the
or an antihistamine (cinnarizine or cyproheptadine) may be
return to normal health. An essential step in making the diag-
justified. No data are available on triptans as an abortive treat-
nosis is the exclusion of other possible causes of recurrent
ment of BPV and they cannot be recommended at this stage.
abdominal pain. Clues to other causes include non-midline or

Full assessment based on clinical

features of CVS and/or AM

Typical of CVS and/or AM Typical of CVS and/or AM Atypical clinical features of

≥2 episodes (Rome IV Criteria) <2 episodes (Rome IV Criteria) CVS and/or AM
≥5 episodes (ICHD 3 Criteria) <5 episodes (ICHD 3 Criteria) or red flags

Invesgaons are not necessary Invesgaons may be necessary according to system involved

Gastrointesnal tract Renal system Metabolic invesgaons if Neurologic invesgaons if

Diarrhoea, conspaon, urine infecon, episodes are triggered by seizures, focal deficits,
melena, weight loss etc. haematuria, fasng or intercurrent squint, ataxia, papillodema,
hypertension illnesses etc.

Figure 1 Assessment flow chart of AM and CVS.

PAEDIATRICS AND CHILD HEALTH 32:10 391 Ó 2022 Elsevier Ltd. All rights reserved.
 OCCASIONAL REVIEW

‘burning’ abdominal pain, pain lasting less than an hour, the Cyclical vomiting syndrome (CVS)
presence of symptoms in between attacks, pain that does not
CVS is closely related to migraine and has been discussed in a
interfere with daily activities, and symptoms attributed to
previous article published in this journal in 2020. The prevalence
another gastrointestinal disease as constipation, diarrhoea and
of CVS has been estimated from population-based studies to be
weight loss. Criteria for the diagnosis of AM are similar in both
around 2% of school-aged children. The peak age of onset is five
the ICHD-3 and Rome IV for Functional Gastrointestinal disor-
years, but CVS has also been described in people of all ages, from
ders (Table 2).
infancy to old age. CVS is characterized by recurrent episodes of
Investigations are only necessary if the clinical presentation is
intense nausea and vomiting lasting between 2 hours and three
atypical or there are additional symptoms or findings on the
days. Episodes are often unprovoked and occur with stereotypic
clinical examination that may indicate an alternate diagnosis
periodicity and clinical presentation.
(Figure 1).
Akin to migraine headache, episodes display three phases:
Investigations are usually unnecessary with the typical clinical
premonitory symptoms of mood change, yawning, food cravings
presentation, but if other underlying conditions cannot be
and heightened perception, an ictal phase of intense nausea,
excluded safely on clinical grounds, first-line investigations may
vomiting, lethargy, pallor, abdominal pain and/or headache
include full blood count, serum electrolytes, urea, creatinine, liver
followed by a recovery phase. Vomiting can be severe enough to
function tests, C-reactive protein (CRP), urinalysis and culture,
cause dehydration requiring hospital admission for intravenous
and abdominal ultrasound scan.
fluid replacement.
Both AM and migraine headache commonly co-exist more
The diagnosis of CVS is clinical, based on fulfilling the criteria
than would be expected by chance. Population-based studies
set out by ICHD-3 and the Rome IV consensus (Table 3). How-
have identified common triggers (tiredness, travel, emotional
ever, as in the case with AM, the diagnosis of CVS requires
stress and missed meals), similar associated symptoms (nausea,
careful clinical assessment to exclude other metabolic, intracra-
vomiting, dizziness, intolerance to light, noise and exercise) and
nial, renal and gastrointestinal causes of vomiting (Figure 1).
common relieving factors (rest, sleep and simple analgesia). One
Because of the wide range of underlying conditions and lack
third to one half of children with AM develop migraine head-
of a specific biomarker of CVS, the choice of investigations is
aches as they reach adolescence. There is a strong family history
often challenging, and tests should be selected based on clinical
of migraine in first degree relatives.
presentation and suspicion.4
On making the positive diagnosis of AM, children and parents
Like other migraine syndrome disorders, the pathogenesis of
should be given an explanation of the disorder and its relation-
CVS is not well understood. Proposed pathophysiological mecha-
ship to migraine. Pharmacological treatment of acute episodes
nisms common to both CVS and abdominal migraine include
consists of simple analgesia and antiemetics if necessary. Chil-
mitochondrial polymorphisms and ion channelopathies such as
dren should be advised to take rest and maintain adequate hy-
that involving ryanodine (RYR2). Triggers to attacks and relieving
dration during attacks. Nasal sumatriptan can be tried in children
factors of CVS resemble AM and migraine headaches. Associated
over 12 years of age. Non-pharmacological prevention may
features such as tiredness, mood changes and sensitivity to light/
include advice on a healthy lifestyle, including regular meals,
noise are common to all these conditions. Long term follow-up of
sleeping routine and exercise. Preventive treatment may be
young children with CVS shows that 79% have migraine head-
needed if the episodes of AM are frequent, prolonged, distressing
aches in adolescence, more than would be expected by chance.
and have a poor response to acute treatment. Unfortunately,
The main aim of treating acute episodes is to stop vomiting
evidence for preventive treatment of AM is derived from open
and prevent dehydration. Both sumatriptan (either by subcu-
studies or small trials. Medications commonly used are pizotifen,
taneous injection or nasal spray) and a reliably absorbed anti-
amitriptyline or flunarizine, which should be tried for at least 6
emetic formulation such as orodispersible ondansetron should be
e8 weeks before its effectiveness can be correctly judged.
given as soon as possible after symptom onset. Co-use of

Criteria for the diagnosis of CVS

ICHD 3 (2018)1 Rome IV (2016)2

A. At least 5 attacks of intense nausea and vomiting, fulfilling criteria Must include all of the following:
B and C 1. The occurrence of 2 or more periods of intense, unremitting
B. Stereotypical in an individual patient and recurring with predictable nausea and paroxysmal vomiting, lasting hours to days,
periodicity within a 6-month period.
C. All of the following: 2. Episodes are stereotypical in each patient
1. nausea and vomiting occur at least 4 times per hour 3. Episodes are separated by weeks to months, with return to
1. attacks last 1 hour and up to 10 days baseline health between episodes.
2. attacks occur at least 1 week apart 4. After appropriate medical evaluation, the symptoms cannot
D. Complete freedom from symptoms between attacks. be attributed to another condition.
E. Not attributed to another disorder.

Table 3

PAEDIATRICS AND CHILD HEALTH 32:10 392 Ó 2022 Elsevier Ltd. All rights reserved.
 OCCASIONAL REVIEW

Key features of migraine syndrome disorders

IC BPT BPV CVS AM Migraine

Age of onset 0e3 months 1e2 years 2e5 years 4e7 years 5e10 years >2 years
Duration of 2e4 hours 2e48 hours 2e12 hours 2e72 hours 2e72 hours 2e72 hours
episode
Sensory Allodynia Photophobia Dizziness Photophobia, Phonophobia Photophobia, Photophobia,
impairment Phonophobia Phonophobia,
Allodynia
Vasomotor Pallor Pallor Pallor Pallor Pallor Pallor
GI upset Possible abdominal Nausea, Nausea, Abdominal pain, Nausea, Nausea, Vomiting Nausea, Vomiting
pain Vomiting Vomiting Vomiting
Between Normal Normal Normal Normal Normal Normal
episodes

Table 4

lorazepam alongside ondansetron may be helpful. Alternative FURTHER READING

treatments including intravenous ketorolac, ketamine and the
neurokinin-1 receptor antagonist aprepitant may be effective in
some children. Non-pharmacologic preventative treatment
should include avoidance of known triggers and promotion of a
healthy lifestyle with good sleep hygiene and avoidance of pro-
longed fasting. Some data show the efficacy of migraine pre-
ventive agents in CVS, most notably amitriptyline,
cyproheptadine (H1-antihistamine), and propranolol. The first
two appear to have similar efficacy, though in one study, pro-
pranolol was shown to be superior to amitriptyline. Aprepitant
and nutraceuticals such as co-enzyme Q10 may have roles for
persistent nausea, although evidence is limited to open-label,
retrospective studies.
Abu-Arafeh I. Cyclical vomiting syndrome. Paediatr Child Health 2020;
30: 350e5.
Abu-Arafeh I, Russell G. Prevalence and clinical features of abdominal
migraine compared to those with migraine headache. Arch Dis
Child 1995; 72: 413e7.
Angus-Leppan H, Saatci D, Sutcliffe A, Giuloff R. Abdominal migraine.
BMJ 2018; 360: 2e10. https://doi.org/10.1136/bmj.k179.
NICE guidance for infant colic, updated 2017. Available at: Scenario:
Management | Management | Colic - infantile | CKS | NICE.
Tarantino S, Capuano A, Torriero R, et al. Migraine equivalents as part
of migraine syndrome in childhood. Pediatr Neurol 2014; 51:
645e9.

Summary and conclusions Practice points

The association between migraine disorders, as summarized in
Table 4, is based on their paroxysmal nature, closely related
clinical features, epidemiology, prognosis, co-existence in the
same patient and their relatives, and in some cases, shared mo-
lecular genetics. A C
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2 Hyams JS, Di LoRenzo C, Saps M, Shulman RJ, Staiano A, van
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3 Abu-Arafeh I, Gelfand AA. The Childhood migraine syndrome. Nat
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s41582-021-00497-6.
4 Raucci U, Borelli O, Di Nardo G, et al. Cyclic vomiting syndrome in
children. Front Neurol, 2020; https://doi.org/10.3389/fneur.2020.
583425.
C Migraine is a common brain disorder with complex genetic
aetiology and pathogenesis
C The migraine syndrome has variable clinical expression in
children.
IC, BPT, BPV, CVS and AM share similar epidemiology,
clinical presentations, genetic and familial occurrence to
migraine headache.
C The diagnosis of childhood migraine syndrome should be
based on defined clinical criteria such as those of ICHD 3 or
Rome IV
C Investigations to exclude other conditions may be neces-
sary if the clinical presentation is atypical or there is no
resolution between episodes.
C Management of children and adolescents with childhood
migraine syndrome is symptomatic, though preventive
treatment may be required in some patients
C More clinical trials of migraine syndrome involving children
and adolescents would expand options for migraine
prevention

PAEDIATRICS AND CHILD HEALTH 32:10 393 Ó 2022 Elsevier Ltd. All rights reserved.