Migraine Affects School Performance in Children

Pauline Anderson

October 31, 2012

Preadolescent children with migraine are more likely to perform poorly in school compared with their classmates without migraine, and they are more likely to miss school than children coping with episodic tension-type headache (ETTH), a new study shows.

Researchers found that 3 main factors — headache frequency, having nausea during an attack, and having to deal with hyperactivity, conduct issues, or other behavioral or emotional problems — all help drive this association.

"To the best of our knowledge, these 3 determinants of poor performance at school in children with migraine have not been described," said study author Marcelo E. Bigal, MD, PhD, Office of the Chief Medical Officer, Merck & Co., Inc., and Department of Neurology, Albert Einstein College of Medicine, New York City.

Dr. Marcelo Bigal

"The good news is that they provide an opportunity for healthcare providers," he told Medscape Medical News. "Frequency of headache and associated symptoms can be ameliorated with treatment, and comorbidities can be identified and interventions proposed."

Dr. Bigal hopes the study will raise awareness about the burden of migraine on youngsters and that pediatricians will dedicate more time to identifying those children who require intervention.

The study is published in the October 30 issue of Neurology.

Learning Child Project

This report is part of The Learning Child project that is investigating disorders that may affect learning in preadolescent children. A network of doctors, psychologists, teachers, and other professionals participates in the project.

The current study included data on 5671 students aged 5 to 12 years who were enrolled at schools in 87 cities in 18 Brazilian states. Volunteer teachers used a scale derived from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition to assess children for the presence of symptoms of attention-deficit/hyperactivity disorders. Children were ranked in terms of overall academic achievement (average, below average, or above average) from competencies in language, mathematics, science, and social studies.

The teachers were also trained to interview the mothers of the students. In addition to sociodemographic information, they gathered data on each child's physical and mental health using the Brazilian version of the Strength and Difficulties Questionnaire (SDQ). From responses to several questions assessing headache features, children were assigned a headache diagnosis: episodic migraine (EP), probable migraine (PM), ETTH (used as a control group for assessing absenteeism due to headache), and chronic migraine (CM).

About one fifth (20.6%) of the children did not report headaches. EM was seen in 9% of the children, PM was diagnosed in 17.6%, and CM in 0.6%. Although the study did not focus on the prevalence of headaches in the preadolescent population, these rates were in line with those reported in other studies, said the authors.

Compared to children with no headache, children with migraine overall, those with EM, with CM, and with PM were significantly more likely to have a school performance that was below average. The risk was not significantly increased for children with ETTH.

Table. Risk of Below-Average School Performance by Migraine Type vs No Migraine

Headache Type Relative Risk 95% Confidence Interval
Migraine 1.30 1.14 - 1.48
EM 1.40 1.19 - 1.66
CM 1.60 1.03 - 2.50
PM 1.23 1.06 - 1.43


It makes sense that CM would have the greatest effect on school performance because it involves more headaches, said Dr. Bigal. Children with EM have fewer than 15 days of headache per month, whereas those with CM have 15 or more.

In children with any migraine subtype, poor performance at school was most significantly influenced by the duration of the headache attacks, the headache severity, the presence of nausea during attacks, or abnormal SDQ total scores (all P < .001).

Although pain related to migraine can make concentration difficult, it may not be the most important driver in the relationship between headaches and school performance, said Dr. Bigal, who pointed out that the results were very different in migraine relative to tension-type headache.

"There is more than pain in determining the burden of migraine," he said. "It could be the associated symptoms, but it could also be that the cascade of neurological events that cause pain in migraine also affect sensorial processing, transiently disturbing learning."

Children with migraine were more likely than children with ETTH to have missed at least 1 day of school because of headache over the past 6 months, and also to have missed multiple days (P < .01 for both).

But Dr. Bigal feels that missing school is not the main reasons for poorer academic performance among children with migraine. "Although children with migraine did miss more school days due to the headache, the number of missed days did not seem enough to justify an important drop in school performance," he said.

He added that future studies should explore cognitive abilities in children with migraine in the days immediately before or after the headache phase. "It is established that headache attacks affect cognition," he said. "We question whether the premonitory or postdromic phases of these attacks are also associated with some form of impairment."

Although the researchers did not differentiate migraine with aura from migraine without aura because of the difficulty of doing this with questionnaires, Dr. Bigal said that he thought that aura is another factor, along with migraine frequency and having associated symptoms that would increase the effects of migraine on academic performance.

Using trained teachers to administer standard questionnaires in interviews with mothers increased participation rates and improved the quality of the data, according to the authors. "Using doctors becomes unnecessary, expensive, and logistically prohibitive," added Dr. Bigal. "Since teachers are educated, are the ones in charge of assessing school performance, and are known by the parents, their use was considered optimal."

The study results underline the importance of determining which children are affected the most by migraine, said Dr. Bigal. "Not all children with migraine are the same. Some have no impact and have infrequent attacks that respond spontaneously and others can have their attacks managed with over-the-counter medications. But some will have significant suffering during the attacks, with impact on their school performance, social life, and peer relationships."

Such an approach, he said, avoids undertreating those in need and overtreating others unnecessarily.

Design "Compelling"

Invited to comment, Daniel Kantor, MD, president of the Florida Society of Neurology and medical director of Neurologique, an organization dedicated to patient-centered care, research, and education, said the study adds important information to the understanding of how migraines affect school performance in preadolescents.

"While it may seem intuitive that migraines can impact school performance, this study measured multiple variables that may contribute to poor school performance," and it found that more frequent, longer, and more severe migraines, having associated nausea, and coming from a poorer home all play a role, he said.

Employing teachers, who may be more likely than medical personnel to interact with families, to do the testing enhanced the study design, said Dr. Kantor, who is also a member of the American Academy of Neurology.

"The study design was actually one of the most compelling aspects of the study, since it used non-trained professionals in the field to help better characterize the impact of migraine on school performance. This may lead to greater buy-in by the general public, and the results may have a longer-lasting impact on public health and even policy issues."

Dr. Kantor agreed that the results would not have been drastically different had the authors been able to capture data that differentiate migraines with aura from migraines without aura. "Migraines with aura make up a much smaller subset of migraines, and any difference would probably not have stood out statistically," he said. "Conceivably, aura may be an additional risk factor for school performance, but it would not negate the bulk of this study's results."

Asked what he thought might be driving the relationship between poor school performance and migraine among youngsters, Dr. Kantor said it is possible that having migraines disrupts the ability to form neural networks needed for long-lasting learning.

The study is certain to help to raise awareness among doctors, teachers, and parents about the detrimental effects of migraines, said Dr. Kantor. "The results may heighten teacher awareness surrounding the need to alert parents to the presence of migraines and may encourage parents to have their preadolescents evaluated by a physician trained in the diagnosis and treatment of migraine."

Although this study did not look at the question of intervention, Dr. Kantor said that there is reason to believe that actively treating migraines may improve school performance.

The study was conducted without financial support. Dr. Bigal is a fulltime employee of Merck & Co., Inc. Dr. Kantor has disclosed no relevant financial relationships.

Neurology. 2012;79:1881-1888. Abstract