Clinical factors and response to treatment were compared in children < 6 years and older children treated for migraine by nonpharmacologic measures in a pediatric headache clinic at Schneider Children’s Medical Center, Petah Tiqwa, Israel. Treatment involved only good sleep hygiene, additive-free diet, and limited sun exposure. Foods eliminated included smoked lunch-meats, smoked cheese, yellow cheese (high tyramine), chocolate, pizza, and foods containing monosodium glutamate. Of 92 children identified retrospectively in records, 50 boys and 42 girls met study criteria. Ages ranged fromn 3.8 to 17.2 years (mean 9.4 +/- 3.9 years). Thirty-two (15 boys and 17 girls) were aged 6 years or younger at onset of follow-up, and 60 were older. The younger group had a significantly lower frequency of migraine attacks with aura (13 vs 23 patients, P=0.02) and a lower number of migraine attacks per month (6.8 vs 14.08, P= 0.008); disease duration before start of treatment was also shorter (11.34 vs 24.62 months, P= 0.0057). Response to treatment was graded 1 (none), 2 (partial-50% decrease), and 3 (complete- 75% decrease in attacks). Mean ages of patients with grade 1, 2, and 3 responses were 10.588, 9.11, and 8.11 years, respectively (P=0.02). The younger group of patients had a significantly higher percentage with grade 2 or 3 responses as opposed to grade 1 response (73.3% vs 27.7%, P<0.0075). Also, percentages of patients with grade 3 compared to those with grade 1 responses were significantly different in the 2 groups (81.2% vs 38.3%, P<0.001), and on comparison of results for each of the 3 grades (P=0.0003). Nonpharmacological therapy for migraine may be effective in younger children because of shorter disease duration and fewer attacks than in older children. 
COMMENT. The nonpharmacological, “conservative” therapy as described above is predominantly dietary, eliminating additives and foods commonly recognized as migraine triggers, especially cheese and chocolate [2, 3, 4]. Elimination diets, such as the Feingold additive-free diet, advocated in the treatment of the hyperactive child, was found in controlled studies to be mildly effective only in some small groups of younger children. The diet was ineffective in older children (NIH Consensus Panel 1982). Elimination and oligoallergenic diets continue to be used in some European and Australian centers for the treatment of childhood neurobehavioral disorders. Interest in dietary therapy for childhood hyperactivity has waned in the United States, and few neurologists use elimination diets for migraine in practice.
Age seems to be a factor in the effectiveness of dietary therapy for migraine. According to the above, children under 6 years are expected to derive most benefit. However, before eliminating certain foods, specific headache triggers should first be identified by completion of headache diaries. Simultaneous elimination of all known triggers is not generally recommended for nutritional reasons. A well-balanced diet is important, and skipping of meals or fasting should be avoided.