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The Romanian Journal of Child and Adolescent Neurology and Psychiatry

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Authors: Marija Knežević-Pogančev, Nebojša Jović, Danka Filipović , Vesna Ivetić


Migraine headache triggers are usually an integral part of any acute migraine attack. Most of autors note that triggers, identifiable or not, must be present in all attacks of migraine headache. Internal or external, they induce the onset of cortical spreading depression in a pre-existing hyper-excitable cortex of a migraine brain, initiating the process of pain generation (1, 2, 3, 4, 5).

The most common reported trigger factors of children migraine are: certain dietary factors, kinetosis, emotional stress, sleep deprivation, physical activity and exertion, mild hypoglycemia due to skipping meals, excessive sun exposure, high external temperature, starvation, febrile illness, different medications and various chemical substances, photo-stimulation, noise, intensive odors, etc. Only a small number of them is well studied as specific age dependent children migraine trigger factor, and adequately documented in children (6,7,8,9,10,11,12).

We conducted this study to recognize age dependent migraine headache trigger factors.



This research was carried out in the territory of Vojvodina, Serbia’s Northern Province, which has a total population of 2.031,992, according to the last census (in 2002). During the study, which lasted from 1988 to 2008 each year 2000 questionnaires were given to the participants, who were drawn from 23 preschools and 42 grade schools in 9 cities in Vojvodina (Novi Sad, Subotica, Kikinda, Zrenjanin, Vrsac, Bela Crkva, Melenci, Futog and Temerin). In total 24,828 children aged 3-15 years have been included. For statistical data analyzing all children have been divided in 4 age groups: 3-6, 7-9, 10-12 and 13-15 years.

Children were selected according to their month and year of birth, and the first 3 letters of their first name by a multistage, stratified, clustered sampling procedure. This ensured that children could not enter the study twice during the long research period.

The subjects and/or their parents were asked to fill out a questionnaire in their places of residence. Questionnaires were distributed to children and/or their parents, selected by random sampling. The semistructured questionnaire, which was specially developed for this study by the author, was designed according to the International Headache Society criteria. It was a screening questionnaire, which was completed by children and/or their parents together. It included 3 sections: (1) items about the child’s sociodemographic characteristics and his/her family and school; (2) items about the child’s development, and (3) items about headaches including trigger factors, (physical activity, lack of sleep, oversleep, stress, coughing, sneezing, fatigue, reading, specific foods/drinks/odors, alcohol, not eating on time, tobacco smell, light, noise and weather changes).

13.1. The questionnaire was developed in 3 phases. In the first, semi structured interviews with pediatricians and researchers were organized to select relevant domains. The domains for the section about headaches were selected based on the International Classification of Headache Disorders – II criteria (13, 14).

More than 150 possible items were identified. Precise, comprehensive and appropriate items were included in the first form. The possible responses were open-ended options or categorical judgments.

In the second phase, the questionnaire was pretested in semi structured interviews on a small group of children who either did or did not suffer from headaches (16 families were included). This phase aimed to evaluate the face and content validity of the questionnaire. Additionally, the sensitivity was evaluated by correlating the data from the questionnaire and the medical records of the children who had headaches. This phase resulted in a revised version, which was evaluated only on healthy children. Fifty children and adolescents completed the questionnaire twice in 3 weeks. The nonresponse rate, response distributions, graphical response presentation (response inconsistency) and questionnaire burdens (time to complete, formatting, etc.) were analyzed. A number of items were modified or eliminated and the final form included 93 items which required 20 min to complete.

The inclusion criteria were: age 3–15 years, signed informed consent from parents. The exclusion criterion was a previous diagnosis of a disease that has headache as a symptom.

The accuracy of the questionnaire used in this survey was based on classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain, and the revised International Headache Society criteria (13,14).

The mean age of the study subjects was 6 years and 8.5 months [range 3–15 years, standard deviation (SD) 3.22]. The large number of children surveyed allowed for definite conclusions.

The study was conducted in 2 phases: completion of the questionnaire and, for those with recurrent headache (RH), a face-to-face interview. Based on data gathered by the questionnaire, children who had RH underwent an extended interview and neurological examination.

The accuracy of the questionnaire used in this survey was based on International Headache Society criteria. Using the society’s classification codes, migraine was accepted as 1.1–1.7, migraine with aura was 1.2.2–1.2.6, migraine without aura was 1.1 and other migraine syndromes were 1.3–1.7. RH was accepted as all headache types that appeared 1to 3 times per month, without separating them due to specific characteristics. All types of RH (idiopathic or cryptogenic recurrent headaches) that were not migraine were considered as nonmigraine headaches (14).

Due to possible double interview 1.5% and due to missing data 5.5% questionnaires been biased. Separate data according to RH were analyzed for children who had completely answered the questionnaire.

The demographic, clinical and social characteristics were described by age and sex according to headache presence and type. The Hi2 test, Levin test and ANOVA were used as statistical methods. A significance level of 5% was used (p<0.05). All statistical analyses were performed with SPSS 15.0 (SPSS Inc., Chicago, Ill., USA).



Out of 24,828 observed children (12,613 girls and 12,215 boys), 3,682 (2,089 girls and 1,593 boys) reported primary non-migraine recurrent headaches, and 1,349 (5.43%) of them, (780 girls and 569 boys) reported migraine headaches. Migraine headache showed increasing age presence in from 3.04% in age group 3-6 years to 7.58% in age group 13-15 year.

Clearly identified and statistically significant, headache triggers, as direct cause of headache, were recognized in 10.4% of children with non-migraine headaches and in 3.92% of children with migraine headaches.

Lack of sleep as direct headache trigger is equally reported by children with migraine headaches (1,330 of 1,349; 98.6%) and by children with non-migraine headaches (3,476 of 3,682; 94.41%).

Migraine headaches are much more frequently triggered (1,211 of 1,349; 89.77%) than non-migraine headaches (2,150 of 3,682; 58.4%) by motion sickness (kinetosis) (p<0.005).

Different foods were indicated as triggers of migraine attacks in 89.10%, of children with migraine headaches as well as 31.91% of children with non migraine headaches. The most common dietary triggers implicated in migraine attacks in children were: cow’s milk (32.39%), eggs (31.95%), chocolate (29.73%), crispy (20.50%), benzoic acid (28.17%), tomatoes (18.90%), cheese (17.57%), origano (16.23%) and meat (12.16%). Odors as direct headache trigger is reported in 82.95% of examined children with migraine, and in 13.1% with non-migraine headaches. Usually daily routine disturbance as a trigger factor of migraine headache was reported in 81.62% children with migraine syndrome and in 74.2% children with non-migraine headaches (p<0.005). Physical activity tends more often to trigger non-migraine headaches (85.31%) than migraine headaches (74.49%) (p<0.005). Passive tobacco smoking much more often triggers migraine headaches (51.82%) than non-migraine headaches (23.19%) (p<0.005).

Psychical stress was much more frequently reported as a direct trigger of headaches by children with non-migraine headaches (86.9%) than by children with migraine headaches (57.1%) (p<0.005).

Food deprivation (short-term insufficient food intake) significantly affects occurrence of non-migraine headaches, than migraine headaches (p<0.005). In the group of children where food deprivation is a trigger of headache attacks, 32.39% suffer from migraine headaches and 65.29% suffer from non-migraine headaches. Children with non-migraine headaches (78.8%) are in general more susceptable to weather changes than children with migraine headaches (21.28%) (p<0.005) without important age differences.

Using canonical discriminate analysis (coefficient over 0.3) migraine headaches were clearly distinguished from non-migraine headaches according to headache trigger factors. The coefficient of canonical discriminate analysis for so-called “disturbance in usually daily activity” trigger factors of migraine headache attacks was 0.772, for unpleasant odors was 0.541, for various foods was 0.428 and for psychological stress was -0.406. All other investigated trigger factors were not significant (travel sickness, tobacco smoke, acute stress, food deprivation, lack of sleep, oversleeping, overexertion, physical activity).

Table 1. Migraine headache age dependent trigger factors


Lack of sleep – Pearson Chi Square: V 59610, DF 1, p<0.005

Kinetosis – Fisher Exact Test: V 735.350, DF 1, p<0.005

Different food – Linear-by-Linear Association: V 1203.032, p<0.005

Chronic stress – Fisher Exact Test: V 94063. DF 2, p<0.005

Odor – Linear by Linear Association: V 1889.054, DF 1, p<0.005

Physical activity – Pearson Chi Square: V 69510, DF 1, p<0.005

Passive tobacco smoke – Fisher Exact Test: V 532.965, DF 1, p<0.005

Fatigue – Pearson Chi Square: V 55.445, DF 2, p<0.005

Psychological stress – Likelihood Ratio: V 1935.861, DF 1, p<0.005

Other – Pearson Chi Square: 2827.431, DF 1, p<0.005

Table 2. Age dependent canonical discriminating analysis of migraine headache//non-migraine headache trigger factors



Trigger factors, identifiable or not are usually an integral part of migraine headache. Analyzing more than 400 hundred of patients with 1174 migraine headache attacks Leone et all found a mean of 1.5 trigger factors for each migraine headache attack was reported. The most frequent trigger during the study was stress (37% of migraine attacks), with poor sleep (34%), fatigue (32%) and menses (19%) also being widely reported. Stress and fatigue and/or poor sleep were the most frequent described trigger factors combinations (15).

Hauge A.W. et al in 2011. provided new knowledge about factors that in particular patients consistently trigger migraine headache. In the group of 181 particiants, formerly identified with at least one trigger factor that often or always triggered an migraine headache autors identified: too much work, reflected sunlight, too little sleep, red wine, passive smoking, menstruation and perfume. Hormones, light and stress were reported to cause at least 50 % of migraine attacks in 62%, 47% and 42% of participants, respectively (16).

Out of our 24,828 observed children 5.43% reported migraine headaches. Migraine headache showed increasing age presence in from 3.04% in age group 3-6 years to 7.58% in age group 13-15 years, concordant with our previous results (17). The early manifestation of both migraine and tension-type headache predict equally often migraine in puberty with marked changes in concurrent symptoms and pain localization (18). Our results are very similar to ther European population studies’. Wober Bingol’s population study of migraine in children and adolescents, encountered prevalence of migraine in 1.1-5% of children and in 3-17.6% in adolescents (19,20). Describing pediatric headache, as a common health problem, Hershey found migraine in 10.6% of children between the age of 5 and 15 years and in up to 28% of adolescents between the ages of 15 and 19 years (21). Clear triggers as direct causes of migraine headache are occasionally proved in children (10.4%). They are highly significant for occurrence of migraine without aura (p<0.005) (7). The current literature indicates that there are over 300 different migraine attacks trigger factors. In descending order of frequency were cited: sensorial stimuli (75%), sleep deprivation (49%), hunger (48%), environmental factors (47%), food (46%), menses (39%), fatigue (35%), alcohol (28%), sleep excess (27%), caffeine (22%), physical exertion (20%), head trauma (20%), trips (4%), sexual activity (3%), medications (2%), neck movements (2%), smoking (1%) and the use of a low pillow (1%) (7,21). Spierings EL. et al reported stress/tension, not eating on time, fatigue, and lack of sleep as the most common trigger factors for migraine headache. Weather, smell, smoke, and light were trigger factors that distinguished migraine from tension-type headache (22). Chabriat H. et al suggested that similar triggers could precipitate headache of different type (23). Karl N. et al showed that different type of headaches share common prodrome and aura signs and symptoms as well as the same trigger factors. They suggest that similar trigger factors may trigger similar mechanisms and may cause common pre-headache signs and symptoms in all headache types (24). Annequin D. found that migraine headache episodes in children are frequently triggered by several factors: emotional stress (school pressure, vexation, excitement, upset), hypoglycemia, lack or excess of sleep (weekend migraine), sensorial stimulation (loud noise, bright light, strong odor, heat or cold), sympathetic stimulation (sport, physical exercise) (25). Since the days of Hippocrates, there have been numerous anecdotes on foods that can trigger headaches in susceptible individuals. Areteus of Cappadocia (2nd century AD) studied and described dietary factors that trigged heterocrania. Therefore he was advising dietary restrictions of various foods. There is an amazing similarity between his observations and current knowledge on dietary triggers of migraine headaches. Despite a series of experimental studies demonstrating that food and odors cause headache their role remains unclear. The importance of chocolate has been doubted seriously, and scientific evidence for cheese as a precipitating factor is lacking (26). In spite of series of experimental studies it is suggested that subjective sensitivity to certain foods should be examined critically, and proven trigger factors should be avoided. General dietary restrictions have not been proven to be useful.

The age of children is of importance when identifying foods as direct triggers of migraine headaches. Some foods are indicated as direct triggers of migraine attacks by 735 children, mean age 11 years and 8.9 months, whereas 1,339 children, mean age 10 years and 9 months, did not indicate food as a direct trigger of migraine attacks. 1,033 children aged 11 years reported various odors as trigger factors of migraine attacks. This is in favor of slight, but still existing, higher susceptibility of younger children to odors as trigger factors of migraine attacks, and vice versa in regard to foods (7). Kinetosis is less important trigger factor in older children while food as trigger factor is better recognized in older children (7). Frequent traveling, food items and changes in weather conditions and temperature exhibited a substantial positive association with migraine headache.

Psychological (mental, emotional) stress is a trigger factor for migraine headache in older children. It is three times more frequent in oldest than in youngest observed group. Usually daily routine disturbance as a trigger factor of migraine headache was reported in 81.62% children with migraine syndrome, twice more often in the youngest group. They mostly affect migraines without aura (7). Physical activity tends to trigger non-migraine headaches more often than migraine headaches - more often in younger children. Tobacco smoke is migraine headache trigger factoring twice more often in younger children (7).

Rossi LN et all using Seshia revision of the criteria for migraine without aura in 320 children (mean age 9.9) found that children with migraine when compared with those with tension headache showed a higher number of trigger factors (exposure to TV or a computer, sleep deficiency, and strong emotions) (27). Psychological stress was much more frequently reported as a direct trigger of headaches by children with non-migraine headaches than by children with migraine headaches (p<0.0001). Psychological stress cannot be considered and discussed as a trigger factor of migraine headaches (7). Fatigue, mental stress, and lack of sleep are the main migraine headache triggers in most reports. Overexertion cannot be considered as a migraine headache trigger in children, although it is often claimed to be a migraine trigger in adults. There is no significant difference in the group of children with recurrent headaches (92.3%), non-migraine headaches (93.1%) and migraine headaches (99.2%) (7).

Trigger factors are important for two main reasons. Firstly, they may provide some clues to the pathogenesis of migraine. Secondly, by avoiding them, drug therapy may be obviated. There are a lot of trigger factors in migraine but the mechanism by which they produce migraine attacks varies.



Migraine headache trigger factors are clear age dependent in children. Identification of migraine trigger factors is extremely important in children. Early age dependent specific age dependent identification and elimination directly provides prevention of migraine headaches in children.



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