High School Start Time and Migraine Frequency in High School Students

Amy A. Gelfand, MD; Sara Pavitt, MD; Kaitlin Greene, MD; Christina L. Szperka, MD; Samantha Irwin, MD; Barbara Grimes, PhD; Isabel E. Allen, PhD


Headache. 2019;59(7):1024-1031. 

In This Article

Abstract and Introduction


Objective: To investigate whether later high school start time is associated with lower migraine frequency in high school students with migraine.

Background: Adequate sleep is thought to be important in managing adolescent migraine. The American Academy of Sleep Medicine recommends teenagers sleep ≥8 hours/night. Adolescents have a physiologically delayed sleep phase, going to bed, and waking later than children and adults. The American Academy of Pediatrics (AAP) accordingly recommends high schools start no earlier than 8:30 AM.

Methods: Cross-sectional observational study of U.S. high schoolers with migraine. Participants were recruited nationally using social media. Respondents attending high schools starting at 8:30 AM or later were compared to those attending earlier start time schools. The primary outcome was headache days/month.

Results: Two hundred and fifty-six subjects constituted the analysis set: 115 later group vs 141 earlier group. Age and sex did not differ. Mean (SD) self-reported headache days/month were 7 (5) vs 8 (7), respectively, (P = .985); mean difference (95% CI for the difference) was −0.8 (−2.3-0.7) days. Median (IQR) self-reported total hours of sleep/school night were: 5.6 (5.0-6.6) vs 5.6 (4.5-6.4), P = .058. Students attending later start time schools woke later (median [IQR] 6:38 AM [55 minutes] vs 6:09 AM [59 minutes], P < .0001) and left home later (median [IQR] 7:28 AM [28 minutes] vs 7:02 AM [60 minutes], P < .0001). Average commute time was also longer: 41 (21) minutes vs 28 (16), P < .0001. The vast majority in both groups reported missing breakfast at least once/week: 103/114 (90.4%) vs 128/141 (90.8%), P = .907. Hours of sleep did not correlate with headache days per month.

Conclusion: High school start time does not have a large effect on headache frequency in high schoolers with migraine. Given the high variance in headache days/month observed in this study, a larger study would be needed to determine whether there might still be a small effect of starting high school at/after 8:30 AM. More research is needed to establish evidence-based recommendations about lifestyle factors in adolescent migraine management.


Migraine is common in adolescents and can cause missed school and disability.[1–3] When migraine frequency is high, daily medication is often offered to decrease headache frequency. However, trials of pharmacologic strategies for decreasing migraine frequency in this age group have not generated consistent evidence of efficacy. While 1 adolescent trial found topiramate effective at decreasing migraine frequency,[4] in the NIH-funded Childhood & Adolescent Migraine Prevention (CHAMP) study, 8-17-year olds with migraine were equally likely to have headache frequency improve if they were treated with placebo, amitriptyline, or topiramate, yet more likely to have side effects on the medications.[5] It has been suggested that active co-interventions may have contributed to the high placebo response rate seen in CHAMP, as participants were seen frequently and counseled about "healthy habits" at each visit—including the importance of maintaining regular sleep.[6]

Evidence suggests there is an important relationship between sleep and migraine across the age spectrum.[7–10] However, one of the societal challenges that adolescents face in their effort to get regular, adequate sleep is that their brains physiologically shift to a naturally later bedtime and later wake-up time,[11] yet their schools often start early in the morning. To address this, the American Academy of Pediatrics (AAP) recommends that high schools and middle schools start no earlier than 8:30 AM in order to accommodate the physiologic needs of adolescents and help them to get the minimum of 8 hours of sleep per night they need to function optimally.[12,13] However, according to the Centers for Disease Control and Prevention (CDC), only about 18% of U.S. high schools comply with this AAP recommendation.[14]

In this study, we hypothesized that high school students with migraine who attend high schools that comply with the AAP recommendation would have lower migraine frequency compared to those whose schools start earlier. If so, and if the effect size was similar to that seen when taking a daily prescription migraine preventive, this would advocate for changes in high school policy to optimize the health of adolescents with migraine.