Pediatric Migraine: A Primer for Teachers and School Nurses

Helping students with migraine stay healthy is an important part of the job for educators and other school staff

By Howard S. Jacobs, MD

Teachers, nurses, counselors and administrators all play a role in the health and wellbeing of children with medical problems. This is particularly true of children with migraine, since they are likely to experience an attack at school. For those with more severe conditions, even their education may be impacted by migraine. This primer on pediatric migraine for teachers and school nurses explains necessary information about the disease and outlines what school staff can do to create a supportive environment for the students living with migraine who attend their schools.

What is pediatric migraine?

Almost 60 percent of children complain of headache at some point. About 8 percent of children experience the pain and disability of migraine. That means that in the average classroom there can be one or possibly two children living with migraine. Knowledge of the disease allows school officials and teachers to help manage students’ symptoms and best support their needs so that they can be successful in the classroom.

Migraine appears to be a genetically determined disease where patients have a “sensitive” brain—the pathways that normally conduct head pain are too easily activated. Children experiencing a migraine attack can have several symptoms that impact their ability to complete school work and participate in daily activities.

Symptoms

The headache associated with migraine is typically moderate-to-severe in pain and is episodic in nature. A migraine attack can last from one hour to several days. Most people think of migraine as being one-sided and throbbing, but often, this is not the case in children and teens, who may complain of a steady, bilateral pain that is often—but not always—located above the eyes. Migraine has associated symptoms that commonly include nausea, vomiting, light sensitivity and sound sensitivity. Some children describe other symptoms such as having difficulty focusing, blurred vision and lightheadedness or dizziness. A minority of children will also have an aura preceding the onset of the migraine. Auras are classically thought to be visual but can affect speech or involve feelings of numbness in the face and arm.

Migraine is further classified based on the frequency at which attacks occur. Episodic migraine is used for patients experiencing less than 15 days per month, and chronic migraine is when patients have more than 15 headache days per month.

How do you treat pediatric migraine?

The treatment of migraine in children typically involves multiple components. Children with primary headache disorders tend to benefit from an overall healthy lifestyle. As the first step in headache management, most physicians will educate families on practices that may help their headaches, such as getting an adequate amount of sleep on a regular schedule, avoiding skipping meals, getting more exercise, staying well hydrated and managing stress.

Another part of treating primary headache diseases is identifying an effective medication that can be taken at the onset of headaches to provide pain relief. The typical goal is pain relief within one hour and the ability to resume or continue daily activities. Typical acute headache medications include over-the-counter agents such as NSAIDs like ibuprofen and naproxen or prescription medications such as triptans like sumatriptan and rizatriptan.

Children who get more than one migraine attack per week may also be treated with additional medication to reduce the frequency and severity of their migraine attacks. These preventive medications (i.e., amitriptyline, topiramate) or supplements (i.e., magnesium, riboflavin) are taken even on days that children do not have headaches and are usually given daily over a course of several months.

How can you help students with migraine?

It is helpful to students and their families if schools are supportive of their efforts to practice healthy habits that might impact the child’s migraine headaches. Physicians might request accommodations such as allowing children to carry bottles of water during the school day or allowing families access to school menus so that meals can be sent from home on days that students are unlikely to eat the offered selections.

Given the significant time teachers and school personnel spend with the children in their care, it is helpful if communication with the family is open and informative. For example, school staff should notify families if children aren’t eating well at school or if children are falling asleep in class and seeming fatigued.

As children with migraine are frequently affected by stress, staff should monitor them and check in at highly stressful times such as when preparing for exams or transitioning to a new school or adjusting to significant changes. It might be necessary to involve school counselors to offer help with stress management. It’s also important to monitor these children for evidence of stressful life events that might be exacerbating their headache disorder such as problems at home or with peers including bullying.

Occasionally, providers may have requests that are specific to the individual patient. For example, it might be asked that a child who experiences photophobia (light sensitivity) be allowed to wear tinted glasses when experiencing migraine symptoms. A child who experiences significant phonophobia (sensitivity to noise) might need to be excused from noisy or loud situations during a migraine attack. It can be helpful, too, if children are allowed a period of rest to recover after taking their migraine medications, for example, waiting 15 minutes in the nurse’s office or being allowed to put their head on their desk for a brief period. There may also be times where schoolwork itself is affected by the migraine attacks; students may need breaks during testing or modified timelines for completing homework.

Furthermore, not being able to participate in desired activities due to symptoms, combined with the feelings of isolation migraine can cause, may lead to depression in students with migraine. Migraine can cause feelings of isolation, and not being able to participate in desired activities can lead to depression. These issues can ultimately worsen a child’s perceptions about their illness and decrease their quality of life. A supportive school environment is key to addressing these problems.

It is important that school be a place where the patient’s migraine treatment plan can be followed and supported. Children who are able to follow their treatment plans at school will tend to have more success in schooling than those children who are unable to do so.

Episodic migraine

The most vital concept is that with migraine, time is of the essence, especially when it comes to students with an episodic disorder. Both migraine-specific medicines and non-specific pain relievers work significantly better when taken at the onset of pain. It is not acceptable to ask students experiencing a migraine attack to “give this a little time and see how you feel in 15 minutes.”

The student’s acute treatment must be administered as-directed at the onset of pain. Allowing the child to get her/his medicine quickly and then have a short time to rest may be adequate enough to get the child back to class. It is important that teachers and school nurses recognize the importance of addressing the child’s headache symptoms promptly and allow students access to their medications.

There will, of course, be times when migraine attacks will be severe enough to cause children to have to miss school; excuses may be sent from health care providers. With effective acute treatment, many children may get relief from their pain and be able to return to class instead of leaving school.

School nurses and teachers should be aware that the vomiting that occurs in association with migraine headaches is not a symptom of a contagious illness. Many children experiencing a migraine headache will have a single episode of very self-limited vomiting that will resolve as the headache resolves. If the child is feeling better, they should not be required to leave school due to vomiting associated with migraine.

Chronic migraine

Children with chronic migraine, in addition to requiring all the help mentioned above, may have more significant needs to allow for success in school. Some children who have become severely disabled from their headaches may have entered homebound schooling programs due to their disease. Part of their treatment goals include helping them to return to their usual activities and schooling, but this is typically a gradual transition back to full coursework. It may be asked that students be accommodated for shortened or alternative attendance hours and/or be offered modified schoolwork regimens as they attempt to return to a regular schedule.

Students with chronic migraine might pose a specific challenge for teachers and other school staff. Many become somewhat acclimated to their discomfort and may seem as though they are not suffering despite describing significant pain levels and experiencing the other migraine symptoms outlined above. This can be quite frustrating to teachers and nurses, which in turn can become frustrating for the student who feels no one believes them.

Doing right by students with migraine

Overall, our goal is to ensure that teachers, nurses, and other school personnel are aware of migraine and the various ways that it may impact students—from those with only episodic attacks to those with chronic migraine who might be experiencing daily symptoms yet show few outward signs. It is important that the child’s school be a supportive environment where his or her migraine treatment plan can be implemented and followed.

Studies have shown that school staff can play a vital role in improving the care of children with migraine. Obviously, it is the goal of all involved, teachers and school staff, medical professionals, parents and the students themselves, to make sure that students living with migraine are successful.

—Howard S. Jacobs, MD, is an associate professor of pediatrics and the co-director of the Pediatric Headache Clinic at the University of Maryland’s Department of Pediatrics.

This blog was updated in March 2020.