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 4: "Maintaining Regular Sleep"

What is the Evidence?

In the Spanish adolescent survey study, several features of sleep were associated with likelihood of having headaches. In univariate analyses, odds of headaches were higher in those with insomnia (OR: 2.3, 95% CI: 1.9–2.9), less than 8 hours of sleep per night (OR: 1.7, 95% CI: 1.4–2.1), daytime sleepiness (OR: 2.3, 95% CI: 1.9–2.9), low sleep efficacy (OR: 1.7, 95% CI: 1.3–2.1), and "non-regular sleeping habits" (OR: 1.6, 95% CI: 1.2–2.0). As above, caffeine use was also associated with higher odds of headaches. However, in multivariate analysis, caffeine and daytime sleepiness fell out of the model. Insomnia (OR: 1.7, 95% CI: 1.3–2.2) and sleeping less than 8 hours (OR: 1.4, 95% CI: 1.1–1.8) remained significant predictors.

However, in the U.S. survey study of high schoolers with migraine, total hours of sleep did not correlate with self-reported headache days per month.[30] Furthermore, sleeping for at least 8 hours per night did not have a significant effect on migraine frequency. That said, the median total hour of sleep self-reported by these adolescents was less than 6 hours per night, with only one in eight respondents getting at least 8 hours of sleep per night.

The American Academy of Sleep Medicine recommends that adolescents get 8 to 10 hours of sleep per night to support optimal health[48] (see Table 2 for recommended sleep durations based on age). As adolescents have a physiologically delayed sleep phase,[49] they generally cannot get to sleep until later at night than younger children or adults. In an effort to help adolescents get adequate sleep, the American Academy of Pediatrics (AAP) recommends that middle schools and high schools start no earlier than 8:30 AM.[50] However, only approximately 18% of schools actually do this.[51] High schoolers who attend schools that follow this recommendation may enjoy a slight decrease in migraine frequency compared with those whose high schools start before 8:30 AM, given that in the survey study self-reported headache frequency per month was 0.8 days lower in the later start time group, (95% CI for the difference −2.3 to 0.7), but this was not statistically significant.[30]

Interestingly, adolescent headache-related emergency department visits are more frequent in the months of September and January relative to summertime, but are not higher during any of the other school-year months.[52] September and January represent the two times of year that adolescents transition back from relatively longer vacations, that is, times during which they may have been able to sleep on their own physiologic schedule, and return back to a more society-driven schedule. This change in sleep pattern, or other changes in schedule, may play a role in activating headache.

In adults, CBT for insomnia (CBTi) has recently been shown to decrease migraine frequency in those with chronic migraine and insomnia.[53] Using a Bayesian completer analysis of two prior randomized control trials (RCTs)[53,54] (n = 43 and n = 31), a brief course of CBTi leads to headache frequency reduction of 6.2 days (95% CrI [credible interval]: −9.7 to −2.7) more than the control group (equated for therapist time and independent skills practice, with information given on lifestyle behaviors) at 6 to 8 weeks posttreatment. This led the authors to conclude that CBTi has a 97.5% chance of reducing headache frequency by at least 2.7 days compared with the control intervention.

Recommendations for the Clinician

Counseling. "Adolescents who sleep less than 8 hours per night are more likely to have recurrent headaches; I recommend that you aim to get at least 8 hours of sleep per night."

Facilitating Implementation. As only 18% of schools follow AAP recommendations, early school start time remains a barrier to getting adequate sleep for many adolescents. Clinicians can advocate within their local school districts for middle and high school start times to be no earlier than 8:30 AM. Recommended accommodations for 504 letters might include reduced volume of homework (to facilitate getting to sleep on time) and/or missing first period to allow adolescents to get at least 8 hours of sleep per night. For those with insomnia, CBTi may be helpful.

Recommendations for Research

Additional research is needed to determine which features(s) of sleep is/are associated with migraine frequency (e.g., sleep onset latency, sleep efficiency, total sleep time, insomnia), and optimal modalities for improving these specific features of sleep.