Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. I'm sure almost every parent listening right now can relate to the feeling of helplessness that takes over when your child is sick or in pain. And for parents of children who suffer from headaches and migraine, questions about what to do and how to help can add to the worry, confusion, and guilt.
What makes it particularly difficult around migraine is that it can sometimes be easy to dismiss some of the symptoms and think they're just from stress — maybe a headache just from too much screen time, or maybe your child is even describing symptoms that could be confused with growing pains.
But when headaches, along with other common migraine symptoms, become frequent, disrupt school or play, and come with nausea, light sensitivity, or fatigue, it's time to take a closer look.
How do you know when it's time to call a doctor? And what causes migraine in kids? And is it possible for them to grow out of them? Most importantly, how can we help our children feel better without overmedicating or missing something that might be an even more serious problem? In today's episode, we'll take a step-by-step approach to pediatric headaches and specifically migraine, separating the myths from the medicine.
So you can feel informed, prepared, and better able to support your child. First, let me introduce my guest, Dr Sara Pavitt. Dr Pavitt is board certified in pediatric neurology and is also a board-certified headache specialist and Chief of the Headache Program with UT Health Austin Pediatric Neurosciences at Dell Children's.
Welcome to the WebMD Health Discovered Podcast.

Sara Pavitt, MD: Thank you, and thank you so much for having me.

Pathak: I am very excited to dig into our conversation today. Full disclosure, because I myself suffer from migraine, and I have an inkling that one of my three daughters is saying things to me that suggest perhaps she also may. This is of personal interest to me as well.

Pavitt: Wonderful. I also have migraine, and so I think that's one of the big drivers for me to get into this field.

Pathak: That's perfect because I did want to ask you about your health discovery or your “aha” moment — whether it's your research or working with patients — that's really impacted what you do in care of patients with migraine.

Pavitt: I love talking about this, so thank you for asking. I think it's important to understand why we come into this field, and for me, I am a pediatric neurologist, which means I did my training in pediatrics and then a training in neurology. But I have a huge passion for really trying to help prevent chronic illness.
And so as I was doing my training in neurology, I had this very impactful clinical experience where I saw a woman in the adult headache clinic. She was 52 years old. She had been living with chronic migraine happening every single day, which had led to multiple years of disability — unable to work.
She couldn't go to her children's basketball games. She was worried about missing their graduation, and she came into clinic and she had never been given a diagnosis of migraine. She had never been given a treatment plan. She was taking over-the-counter medications, and it was really in that moment that I realized, oh my goodness, this disorder — migraine — is a childhood illness typically. And what if I could help identify and treat these patients and hopefully prevent the potential disability that happens and comes later in life?
And so that was really my “aha” moment to say, this is what I want to dedicate my life to. I am excited to care for these children and really, hopefully, give them a tool or pathway so that they can do all of the things that they want to do in their life.

Pathak: That really resonates because I think that oftentimes we don't recognize these symptoms early on in children because they're not saying the same words that we would potentially use as adults. So I'd love to start with that. I think often there is this idea that if you have a headache, you're having migraines, and that if you're a child, you're too young to have a migraine disorder.
So can you first start by helping us understand headache in general and how you come to thinking about migraine being the cause of that headache in a pediatric patient?

Pavitt: Yes. That's a wonderful question. So when we say migraine, it's very specific because we know that migraine tends to be so much more than just a headache. Headache is a big component of it, but it oftentimes has many other symptoms and can have many phases to it.
So oftentimes people will notice that hours to a day before their headache, they might just start to feel more fatigued, have difficulty concentrating. Sometimes people get specific food cravings or want to drink more water.
The actual headache attack phase of a migraine is the one that tends to cause the biggest disability. And when I think about it in general: typically people will have head pain, but also light sensitivity, sound sensitivity, upset stomach or nausea, and then sometimes throw up.
After that phase is done, then people get the — we call it a postdrome — so after that headache phase, people again kind of feel tired, they feel worn out. They don't get back to their normal self usually for another couple of hours or days.
And in children, it's really interesting because if I ask them in clinic, “Do you feel sensitive to light and to sound?” they're like, “No, Dr P, no way. I'm fine.” So it's really exciting because I have to act as a detective to understand how migraine symptoms express themselves in children.
And it's a little bit different. So I often ask the kid, “If you could do anything during a headache attack, what would you want to do?” And if it's migraine, most of the time they tell me, “I want to go lay down in a dark or quiet environment.” Or they might tell me, “When I don't have a headache, I'm completely fine being around my siblings, even if they're arguing, even if we're playing loudly. When I get a headache, I can't do that. I can't be with my siblings because it's just too loud.”

Pathak: Really interesting. I love how you used the term “being a detective” and just asking questions in a way that really resonates or speaks to a child's experience versus these terms that you have to kind of experience and know and learn what they mean before you can say, “Yes, I have this,” or “No, I don't.”
So can you talk to us a little bit about how common migraine is in children? Around what age would you first start asking children these kinds of questions to understand a little bit more about what they're experiencing?

Pavitt: Yeah, so migraine is incredibly common. And even if I take a step back and first think about headache — so, every year about 50% of the population will experience a headache, and migraine, specifically in the pediatric population (so people under the age of 18), it occurs in about 10 to 12% of the population.
So I oftentimes talk to patients around it like: if you are in a classroom and you have 30 kids in your class, about three of them are likely gonna have migraine. So you're not alone — it is a frequent and common disorder. A typical age of onset is around eight or nine years old, so in childhood, but I will say I made the diagnosis of migraine in kids down to the age of three.
So it can really kind of happen throughout that pediatric period into early adulthood. And then one thing I oftentimes hear from a lot of families is, "My kid is too young to have migraine," but my kid is absolutely too young to have something called chronic migraine. And chronic migraine is when we start to have more than 15 headache days a month for more than three months.
So just frequent attacks that are happening for longer periods of time, and we know that that actually occurs in about one to 2% of pediatric patients. If I put that into kind of perspective of other disorders, that's about the same percentage of people who have epilepsy. So it's unfortunately still a really common thing that can happen in our younger population as well.

Pathak: What is it that a parent might be on the lookout for? What are some of the first signs that you would be thinking about in a child?

Pavitt: A lot of times when we talk to parents, they'll say maybe there were some signs this started months to years ago. And so when I think about it, I mentioned that headache in itself is really common and the most common reason for kids to have a headache is from a viral illness. So I kind of put that into one big bucket: if your child is having a headache and they're sick at the same time, it's probably because they're sick and that virus is triggering it.
So if your child is starting to have headaches and there's really not a specific thing that you can think of that may be causing them — especially if those headaches start to have your child modify their behavior, meaning I actually need to sit out from recess, I need to take breaks from my sporting events, I need to come home from school — that starts to tell me that that headache is really more moderate to severe. It's causing some disability and it may have some of those associated symptoms.
So it may be that they need to sit out from soccer practice because it's too bright out and it's too loud. And so they need to cool down. They'll want to, like, put a hat on, put sunglasses on; they may get an upset stomach and have some nausea with their headaches. And so really it's that kind of shifting from a headache that a kid just says, "Oh, mom or dad, I have a headache, but it's okay. I don't need treatment. I'm gonna keep moving with my life," — once it starts to say, "Ooh, I actually need to start modifying my life because I'm having a headache," — that's when I start to really think, "This actually might be migraine." I'd love to ask about factors that you know of that increase a child's risk of developing migraine.
So we know that migraine tends to be genetic, and this is also really interesting: it tends to run in families. If you have it running through one side of your family, you have about a 50% chance of having migraine. Both sides is about a 75% chance of having migraine. But the interesting thing is that migraine can look so different between each family member.
So some people can have really infrequent attacks while others have them much more frequently. And I'll say in my clinic, more often than not, as I'm making the diagnosis of migraine in the child who's sitting in front of me, the parent is also like, "I think I've been having this for the last 30 years. Do the same things you're talking about also apply to me?" And so that genetic setup is one of the biggest risk factors for having migraine. We know there's some other interesting conditions that are associated with migraine. It's not a one-to-one correlation, so if your child has this, it does not mean they're gonna have migraine. But we know that these things can just be more common in kids who have migraine. It's things like motion sickness or car sickness. Growing pains actually are more common in patients who have migraine. And then things like an ice tic or brain freeze — you get brain freezes — that happens more often in patients who have migraine.

Pathak: Are there things that happen in children that could minimize the symptoms of migraine if a child is predisposed or is having migraine attacks already?

Pavitt: Yeah, so like I was saying, we know that migraine is very individualized to each person: each person is going to display their own types of symptoms and then they'll also have their own types of triggers. And when I talk about triggers, it's really important to understand that triggers are cumulative.
So there's actually very few people who, if I do this one specific thing, I will always get a migraine. And sometimes that does happen — there's some specific food triggers where, you know, I always eat this one brand of hot dog and if I do it, I'm gonna get a migraine. But for the majority of people, they're cumulative.
So it's the fact that I have finals and I was up all night studying, and because of that I am stressed because I really wanna do well on my tests and I might not be drinking enough water. And then I was just outside at a football game in the really bright sun. It was really hot. And all of those things together can trigger attacks.
So it's really important, from my perspective, that we really think about an individualized treatment plan that identifies specific triggers that a patient may have and tries to mitigate those triggers in a way that makes sense in their life. So I don't want people to have to completely modify or avoid things, but things like, if you're feeling sensitive to light or if bright lights are a trigger for you, maybe we wear hats. We wear sunglasses. I'm from Texas, and so we talk about this all the time in the summer — making sure that if you're outside playing sports, we have ice water, you have cooling racks, there's places that you can actually go and get into the shade.
So things that we can implement in our life that make sense, that allow us to continue to do the things that we wanna do and help with that threshold of developing a migraine — kind of raising that threshold for an attack to happen.

Pathak: So, so helpful. So I'd love for you to sort of talk to the person who's listening who thinks that maybe their child or a child that they know is exhibiting some of these symptoms. Help us understand why it's so important to seek care, even if you feel like you figured out a good sort of regimen to increase that threshold, and where should they start?

Pavitt: I think first is really understanding why it's important to talk to your healthcare provider about this. When we make the diagnosis of migraine, at this point, we do not have a cure for it. I hope in the next 10, 20 years we do. I tell all my patients, "In your lifetime, my hope is that we have a cure." But right now, when we make that diagnosis, it is a diagnosis that is lifelong because we think that it has a lot to do with the genetics, with your gene. And so we don't have ways to change those. The other really important thing to recognize in this is that migraine can cause significant disability. And when we actually look at the global burden of disability, migraine is the second leading cause of disability in people 16 to 49. So I take a lot of responsibility when I'm making this diagnosis to make sure that my patients recognize what it is. But this is a lifetime diagnosis and it can come with disability.
So why is it so important that you talk to your healthcare provider? Because we want to ensure that we're able to build your treatment plan — your individualized treatment plan — around you so that migraine doesn't cause that disability, so that you have the different tools in your toolbox that you can pull out when you need to. So that you can do everything that you wanna do in your life: graduate from high school, get a job, go to college, get married. All of those things are still very achievable goals.
The second question was talking about how do we talk to our healthcare provider and when do we bring it up? I would say at any point that you kind of feel like your child is having those headaches that are starting to interfere with their ability to do life things. Talk to your primary care provider. Migraine is incredibly common in children and adults, and so we always start with your pediatrician, your family medicine doctor. Talk to them and let them know your concerns, because even if things are really well controlled when you're presenting, it's still good to acknowledge that that's happening so that we know if things change over time, we can actively go down the treatment pathway and then, if needed, we can refer out to other subspecialists for help.

Pathak: So then I'd like to ask you, can you help us understand a little bit more about individualized treatment from trigger identification to medications if necessary? So can you kind of walk us through how you come up with that individualized plan?

Pavitt: Wonderful question. And one of the things I love about practicing in this field is that we have so many options for treating this disorder, and those different options are medication and non-medication. And so there's a lot of different things that we can do to help build that migraine toolbox.
A lot of what we talk about is starting with things like lifestyle regularity. Having those migraine genes means that your nervous system is just a little bit more hypersensitive than someone who doesn't have migraine. So we know that it likes things to be regular and predictable. So we do a lot of talking about regularity and predictability in our sleep schedules.
So going to bed and waking up around the same time, which can be really hard for our adolescents, who naturally—their sleep clock is already shifting to going to bed later and waking up later. But our society says, no, no, you still need to wake up early. So we have to find feasible solutions for them to try and meet them where their biological clock is going.
But also making sure that we're getting enough sleep at night. We talk a lot about hydration. Again, in Texas in the summer, I'm like, there's no minimal amount of water—just keep drinking water. Adding those electrolytes, especially if we're outside. And then meals and timing of meals, making sure we're kind of getting three meals in a day around the same time each day.
We know breakfast is the most commonly skipped meal, so we talk a lot about, with our patients, finding portable solutions—something with protein that can be fast and easy, and they can just do it on their way out to school. And then incorporating physical activity. So physical activity—there have been more studies in adults, but it can be sometimes just as effective as taking a medication every day to help reduce headache frequency.
So we really start with those kinds of principles, understanding and partnering with our patients to say, you know, there's gonna be times in our life where we cannot be perfect with all of these, but how do we find a pattern for your life that is sustainable? And then we talk a lot about other medications and non-medication options.
So there are certain vitamins that we know, if we take every day, can help reduce headache frequency. There are prescription medicines that can reduce headache frequency. We also talk about specific medications that you would take in the moment to treat a migraine attack when they happen—we call those acute medications.
But then we can also layer in things like neuromodulation, which are specific devices that can be helpful in preventing and treating migraine attacks, as well as things like cognitive behavioral therapy, which has some amazing evidence to be helpful in pediatric patients.
Those are done through psychologists, and it's typically an eight-week program that patients go to and learn all about pain and how to retrain the brain in the way that it thinks about pain. So there are all of these different things that we can really utilize, and that's partnering with your healthcare provider to figure out: there are all these options.
Which ones do I choose, and which ones are right for me? That's our job—to help guide them.

Pathak: So are there particular vitamins? And before starting, is this an area where you really should be talking to your pediatrician before you start a vitamin regimen?

Pavitt: Yes. So I do always talk about—even if we're starting vitamins—these are still substances that we're putting into our body. So these are still medications, and it's really important that you're pairing with your healthcare provider so that they know that you're taking these. And most of them are very, very safe in the general population, but each person is different.
And so it's important, in case you have a reason you should not be taking one of these vitamins, that you talk to your healthcare provider before you do.

Pathak: I'd love to dig in a little bit more around stress and stress management. So you talked about cognitive behavioral therapy for rethinking about pain, but how do you address stress—which can often be a trigger in and of itself, but then also makes it much harder to do some of those other lifestyle behaviors that you were talking about?
When you're stressed out, you're not really able to sleep well. You're maybe skipping meals even more so. How do you address that underlying cause?

Pavitt: Yes. So stress is an important factor that we talk a lot about. We know that patients with migraine do have higher rates of mood disorders like anxiety and depression, and so it's important that we identify and we talk about these things. So just as when we're talking about trigger modification and recognition, stress is one of those things that we talk about.
And then we have to talk about ways to help mitigate that stress. And each person, again, is gonna be different based on what's going on with that patient. So it may be utilizing mindful-based stress-reducing apps on our phone. A lot of my patients love some of the apps that they can just get for free on their phone, and that can be really helpful in the moment.
Some patients really prefer going to see a counselor or a therapist, depending on how that stress is interfering potentially with life. We talk a lot about how things like anxiety, depression, and stress go in that cycle with migraine.
So if we're having a lot of stress, a lot of anxiety, it can make our sleep worse; it can make it more difficult to eat breakfast—all of those things, as you just mentioned. And that can actually trigger more frequent migraine attacks.
But then, if we're having more frequent migraine attacks, we're probably missing more school, which is then making us get behind on tests and assignments. And so it can be this really big cycle. And so we talk a lot about the importance of treating everything and not just one thing. You have to treat everything to really be successful at this.

Pathak: I'd love to have your insights on how you address this with parents when you're thinking about all of the trigger management, the preventive lifestyle modifications, and then it comes to a point where your child may need to take a medicine for prevention or a medicine to stop an attack.
I know that I personally have a hard time with that for my children, just because I'm thinking about how many years into the future they're gonna have to be taking these types of medicines. It's necessary, so I'm not suggesting otherwise. But I'd love to hear your insights on how you talk to your patients and their parents around when it's needed and the importance of taking it as prescribed.

Pavitt: We do a lot of partnering with our patients and with our parents, because as a pediatrician, you know, I have multiple people in the room that I need to really understand what their goals are. And so typically in migraine care, if you are seeing a provider, oftentimes they will actually start with recommending one or two trials of the vitamins that we know can be helpful in migraine prevention.
So for most patients, that's where you're gonna start. If we're having frequent attacks or attacks that are causing disability—so, man, we are still missing four or five days of school—that's when we start to have those questions about, or conversations around, maybe it's time to think about prescription medications that could be helpful in reducing that frequency of attacks.
And really it's a conversation with our patients—so understanding what they're looking for and what's feasible in their life and the parent. There are multiple options that we have. And so a lot of it is talking about side-effect profile, understanding what other potential health conditions the child has, and then what's feasible for them.
If they are like, “There is no way, Dr P, I'm gonna remember to take medicine twice a day. I can only do it once a day.” Great. Let's talk about those types of options. And so really it's partnering and finding out what the best kind of treatment plan is for them moving forward. I also think it's incredibly important to understand that when we're putting a patient on a medication every day, it does not mean that we expect them to be on it throughout the rest of their life.
So as a migraine provider, I always talk about once we are stable, we're in a really good place with your migraine attacks for three to six months, we're gonna try and come off of that medication. That brain and that nervous system are rapidly changing throughout childhood and adolescence, and so it's always important that we ask ourselves: What is the time to come off?
I wonder if things have changed and now we're just in a different neurologic state and we're more stable and we might not need that everyday medication.

Pathak: I love that. That is so helpful. So I'd love if you can talk a little bit in our last few minutes together around how exactly, like you said, this is not something that's set in stone forever—that there's a lot of adjusting and really being attuned to the changes that are happening in yourself and the environment around you.

Pavitt: So we do a lot of talking around school time too. So the transition from summertime, where there’s just more flexibility typically in a kid's schedule, and then all of a sudden they have to go back to school and try and manage all the responsibilities with that—that tends to be a big time where we can see migraine attacks become more frequent.
Puberty is another big one. Oftentimes in childhood, migraines aren't causing a lot of disability, but once we see those hormonal changes, the migraine attacks tend to potentially become more frequent and severe. So I think it's important to understand how migraine affects each individual.
If we know there are specific times or specific things that cause increased attack frequency for you, sometimes we just do medications around that time. So I have a couple of patients where we know that transition back into school is a time where we see increased migraine attacks, and so a month before school starts, we start a daily vitamin.
We continue it for two to three months, and then we actually can come off of it for the rest of the year in the summer. So it really is kind of understanding—and some of this takes time—what your cadence is and what your frequency is, but once we get that, we can really understand how to tailor your treatment.

Pathak: And my final question is really around: If you are working with a healthcare provider that may not really be taking some of these symptoms seriously or may be dismissing them in your child, where should parents turn to for help?

Pavitt: This is such an important question, because I think for all families, if I could tell them one thing, it's to understand that there is always something more that we can do. Oftentimes when patients come to see me, I hear a lot of, “Dr Pavitt, we've tried everything.” That is never a mantra. There is always something more that we can do.
And so if you are feeling like the healthcare provider that you are seeing is not providing the treatment plan that you need, I would always recommend asking for a referral to a higher level of care. And so typically within the pediatric population, start with your primary care provider. You might get a referral to a pediatric neurologist, and then if a pediatric neurologist also needs assistance, then to a pediatric headache specialist.
We are few and far between, but we do have centers across the entire country. There are also some amazing patient advocacy organizations that I think are really great ways to help connect with other patients and parents who are living with migraine and can help guide in this navigation of the healthcare system.
So the American Migraine Foundation and the National Headache Foundation are two really great organizations that have a lot of patient advocacy group work with them. And then Migraine at School is another interesting organization that can partner with you in understanding how to help support your child in the most optimal way at school.
So those are some kind of outside organizations beyond your provider interaction that can be really, really helpful.

Pathak: That's really helpful. Thank you so much for those resources. I think that's critical because sometimes only somebody else experiencing the condition can give you a lot of the insights around the day-to-day, beyond what your caring healthcare team can do for you as well. I'd love to close our time together with just your final thoughts.
For someone who's listening today and is recognizing a lot of what you're saying is happening in their lives, what are those best next steps that you'd advise them to take?

Pavitt: I would say to not be afraid of asking the questions—going to your care provider, asking the questions—and in general, feel hopeful. Migraine care has changed so much over the last 20 and 30 years, and we are rapidly evolving all of the time. So even if you are given this diagnosis, if your child is given this diagnosis, be really hopeful for the future because we do have all these different strategies and all these different things that we can do to ensure that your child is going to meet all the goals that they want to in their life.

Pathak: Thank you so much. Really, really appreciate this conversation.

Pavitt: Oh, thank you so much for having me.

Pathak: Before we close our episode, I'd like to share my three key takeaways. First, headaches in children are common, but frequent or disabling pain that disrupts their ability to function absolutely deserves attention. If your child is missing school, skipping activities, or needing to lie down in a dark room because of a headache, it's time to talk with your pediatrician.
These could be signs of migraine, which affect about one in 10 children. Early recognition can prevent symptoms from worsening, improve your child's quality of life, and reduce long-term impact.
Second, migraine is more than just a bad headache. Children may not have the experience or language to describe their migraine symptoms the way an adult would. They might use nonverbal behaviors to communicate what we generally might say out loud, like “I'm having light sensitivity,” or “I'm having photophobia.” A child might curl up in a ball to decrease stimulation and withdraw from light triggers, or cover their eyes to reduce light exposure. It's important to pay attention to their behavior changes as well as their words.
Knowing your child's pattern can help you both track when and how headaches begin, when they might be escalating, and might help you identify triggers.
And finally, hope and help are out there. Migraine management has evolved dramatically, and with the right support, most children can thrive without missing out on all the things they love. Individualized treatment is key. It's important to work with your child's healthcare providers to make lifestyle adjustments like improving their sleep routine, staying hydrated, and ensuring regular mealtimes. Your healthcare provider—specifically a headache specialist—might be able to help you understand the right vitamins to take and the proper doses.
This is not a one-size-fits-all approach. And a healthcare provider can also help link you with other tools like cognitive behavioral therapy and certain medications.
To find out more information about Dr Sara Pavitt, headaches, and migraine, make sure to check out our show notes. Thank you so much for listening.
Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected].
This is Dr Neha Pathak for the WebMD Health Discovered Podcast.