TABLE 9–4.

SMART (Sleep, Meals, Activity, Relaxation, Triggers) Lifestyle Considerations3

Factor	Advice
Sleep: consistent and sufficient
Bedtime and wake-up time	Maintain a consistent bedtime routine and avoid daytime napping to prevent disruptions to the sleep-wake cycle99; children 3–5 years of age should sleep 10–13 hours per day (including naps), children 6–12 years of age should sleep 9–12 hours per day, and teenagers should sleep 8–10 hours per day100
Problems falling asleep	Use bed only for sleep, turn off screens at least 1–2 hours before bed to limit blue light exposure101
Problems staying asleep	Consider causes such as sleep apnea, depression
Daytime somnolence	Consider causes such as sleep apnea, depression
Meals and hydration: consistent and sufficient
Missed meals	Recognize that fasting can be a trigger
Well-balanced diet	Eat a variety of fruits and vegetables, protein, and dairy (or another source of vitamin D)
Access problems or limited time	Address time limitations and food insecurity with individualized solutions; consider social work consult
Water consumption	≥8 cups per day for children older than 9 years of age (more for teenage boys and extra at times of high exertion)102
Other beverage consumption	Limit to avoid weight gain as obesity is associated with worsened migraine frequency and disability21
Caffeine consumption	High caffeine consumption is associated with increased odds of headache in adolescents,95 probably because of caffeine withdrawal103
Activity: consistent and sufficient
Address inactivity	Inactivity in adolescents is associated with higher odds of migraine95; weight loss in overweight teenagers can contribute to headache improvement21
Exercise	Meta-analyses in adults have concluded that exercise may be a beneficial and safe treatment for migraine104
Relaxation: cope with stress and prevent migraines
Sources of stress	Home-related stressors (eg, arguments with siblings, observing parental disagreements) or school-related stressors (eg, difficulty in school, fear of doing poorly) can be triggers for headache
Help cope with stressors	Validate the normalcy and commonality of stressors and discuss coping strategies
Relaxation strategies	Cognitive-behavioral therapy can help migraine in children105; mindfulness-based stress reduction looks promising106
Triggers: avoidance/management
Weather	Changes in weather patterns are commonly reported as headache triggers; use of long-acting triptans may help to prevent migraine attacks around storms107
Specific foods	Little evidence shows that foods other than alcohol and caffeine are consistent headache triggers, although many patients report avoiding specific foods
Menses	Refer to the section on menstrual migraine

^aModified with permission from Blume HK, Szperka CL, Pediatr Ann.⁴⁰ © 2010 SLACK Incorporated.