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


While some clinicians may already consider it standard of care to counsel children and adolescents with migraine about hydration, meals, exercise, and sleep, the evidence-base in this age group to support these recommendations for migraine prevention is relatively thin. Before we get too heavy-handed in asking patients and families to make changes to their lifestyle and adhere to them, we need additional research to determine which behavioral interventions truly influence migraine frequency in this age group.

As with all biobehavioral research, it may be challenging to design research studies that can separate out single variable effects. For example, it may be difficult to separate the effect of fasting from the effect of not drinking water, or from caffeine withdrawal. Moreover, perhaps it is even inappropriate to do so as it is possible that lifestyle interventions somehow "all work together," if at all. For example, in an observational study of ≥15-year-olds with migraine being seen at a headache clinic, those who followed a "triumvirate" of "regular lifestyle behaviors"—scheduled sleep pattern, regular mealtimes, and daily exercise—were less likely to have chronic migraine than those who did not,[55] with regular sleep appearing to be the most important contributor. Certainly some of these lifestyle factors may influence one another. For example, not getting enough sleep may lead adolescents to have more rushed mornings and increase the likelihood of missing breakfast and needing to drink caffeine.

In addition, the "dose," or format, of biobehavioral treatment needed to have an effect on migraine may be hard to know a priori, and we run the risk of false-negative results. For example, if what matters for decreasing migraine frequency is keeping to a regular sleep schedule that varies minimally between weekdays and weeknights, but the study intervention focuses only on increasing total sleep time without decreasing sleep schedule variability, no effect may be observed and this might lead researchers to erroneously conclude that sleep has no effect on pediatric migraine.

Despite these inherent challenges, this is an area of neurologic knowledge well worth pursuing. If lifestyle interventions can improve children and adolescents' migraine frequency, this would be of enormous benefit with potentially fewer side effects than medications. As asking for behavior change does take effort on the part of patients and their families, and there is the potential to magnify migraine stigma if we blame patients for not making these changes, we need to approach this topic with the same level of scientific rigor as we do medication therapy.