Childhood migraine headache syndromes

•The treatment of migraine headache in children depends on the following: a) defining the underlying cause; b) the frequency of the attacks; and c) the severity of the disability produced by the pain.•Any medication taken to relieve pain is most effective if taken at maximum dose at the onset of the headache. The dose should be the maximum recommended by weight or age. Triptans are also more effective if used early.•Over-the-counter (OTC) analgesics are often effective in relieving pediatric headache and should be tried before prescription drug therapy is attempted.•The more frequent a child’s headaches are, the greater the danger that repeated doses of pain medications, including those purchased OTC, will lead to a chronic headache syndrome as the medication is reduced.•Recurrent severe headaches, occurring more than once a week and resulting in interruption of normal activities or poor concentration, need to be treated with prophylactic medications taken daily so that the number of headaches can be reduced. Amitriptyline, propanolol, and periactin are the most frequently used drugs to block headaches, but valproate, verapamil, or other calcium channel blockers and other antidepressants are also useful.•Biofeedback, relaxation, or cognitive therapies can also reduce headache frequency in children with both migraine and tension headaches.•Headaches that are intractable to oral medication for the acute relief of pain may respond more rapidly to an efficiently absorbed drug administered by nasal spray or subcutaneously.•The initial dose of an injectable drug should be given in a situation where a physician is immediately available.•Recurrent headaches that have occurred over more than 6 months and that are associated with a normal neurologic examination are almost never caused by an intracranial lesion. Routine CT and MRI scans or an electroencephalogram (EEG) are generally unnecessary for these patients because these scans are rarely of value in these patients unless there is a history of another neurologic disorder or the headaches are focal, relentless, and worsening over time.