Lifestyle Advice for Pediatric Migraine: Blaming the Patient, or Evidence Based?

Amy A. Gelfand, MD, MAS; Samantha L. Irwin, MBBS


Semin Neurol. 2020;40(3):277-285. 

In This Article

Section 1: "Adequate Hydration"

What is the Evidence?

There is evidence that, in general, most children and adolescents tend to be mildly dehydrated. Based on tests of urine concentration, 54.5% of 6- to 19-year-olds are mildly dehydrated.[9] However, we are not aware of any data examining whether drinking more water helps decrease headache frequency in pediatric migraine.

Nonetheless, there are data examining how adherent adolescents with migraine are to advice to drink water. Adolescents seen at a tertiary pediatric headache clinic enrolled in a study where they self-reported their water intake on a device after having been advised to drink 8 to 10 glasses of noncaffeinated liquid per day. It was observed that the participants drank an average of five (standard deviation [SD]: 3) glasses per day. The results were interpreted to indicate that "pediatric migraine treatment could place more emphasis on adherence to lifestyle interventions to potentially provide greater reductions in frequency and intensity of migraine."[8]

In a pilot study of 18 adults with migraine, participants were randomized to either a placebo or advice to increase water intake by 1.5 L daily. The actual increase in water intake observed was approximately 1 L per day. Over a 2-week period, the increased water intake was associated with decreased hours of headache (−21, 95% confidence interval (CI): −48 to 5) and lower mean headache intensity on a visual analog scale (−13 mm, 95% CI: −32 to 5), though neither finding was statistically significant. In another study of adults with recurrent headaches, all participants received advice about stress management and sleep, and the intervention group also received advice to increase water intake by 1.5 L per day. Those drinking less than 2.5 L per day at baseline were eligible for inclusion. The increased water intake advice group (n = 52) scored somewhat better on a migraine quality-of-life scale than those in the control group (n = 50), but there was no reduction in headache days (defined as days with at least moderate headache) in this 3-month study.[10] As a line of potentially relevant evidence, adults are more likely to present to an emergency room for headache when the weather is warmer, which could be related to hydration status, though alternatively internal or ambient temperatures, or simply sun exposure, may drive this observation.[11]

The Institute of Medicine does not set specific requirements for total water intake for the general population. Instead, they provide adequate intake estimates based on what the median intake is among individuals of various ages and sexes who seem adequately hydrated. These "adequate intake" parameters include total water intake, that is, from food as well as beverages. Food accounts for approximately 15 to 20% of water intake. The report notes that higher water intake will be needed for those who are physically active or in hot environments. See Table 1 for adequate intake parameters by age and sex.[12]

Contrary perhaps to popular belief, the Institute of Medicine report does not conclude that caffeine leads to overall water loss from the body. Therefore, caffeine-containing beverages are considered to contribute to total water intake just as non–caffeine-containing ones. The report reads, "Hence, unless additional evidence becomes available indicating cumulative total water deficits in individuals with habitual intakes of significant amounts of caffeine, caffeinated beverages appear to contribute to the daily total water intake similar to that contributed by noncaffeinated beverages."[12] Whether caffeine intake, or more likely caffeine withdrawal, contributes to activation of migraine is another matter.

Recommendations for the Clinician

Counseling. "The majority of people your age probably aren't drinking enough water. There is some evidence from adults with migraine that increasing water intake might decrease headache intensity and duration." Our pediatric headache team simplifies the information found in the adequate intake table to a general recommendation that patients ingest "1 ounce of fluid per kilogram of body weight" daily, adjusted for heat and exertion where needed.

Facilitating Implementation. Consider including in 504 support letters that the student should be allowed to carry a water bottle and keep one at their desk. Having a water dispenser with cups has been shown to increase the odds that middle schoolers will drink water at school compared with only having drinking fountains.[13] Students with migraine also need regular bathroom breaks to process their water intake. (A written letter from a doctor is sometimes needed in order for school children to have unfettered access to water and toilet facilities.) The Centers for Disease Control and Prevention (CDC) has toolkits schools can use to improve access to drinking water.[14]

Recommendations for Research

Randomized, controlled trials are needed to determine whether increasing water intake decreases migraine frequency in children and adolescents.