Headaches in Children and Adolescents
How common are headaches in children and adolescents?
Headaches are very common in children and adolescents. In one
study, 56% of boys and 74% of girls between the ages of 12 and 17 reported
having had a headache within the past month. Many parents worry that their
child’s headache is the sign of a brain tumor or serious medical condition, but
most headaches in children and adolescents are benign and are not the result of
a serious underlying disease.
Many headaches in children and adolescents are the result of
stress and lifestyle issues. Headaches are also common symptoms of infections,
colds, and the flu. The most common types of headaches in children and
adolescents are muscle tension and migraine. By age 15, 7 to 10% of all children
and adolescents have had migraines and 15 to 20% have had frequent
non-progressive or tension headaches.
What are the types of headaches?
A comprehensive headache classification guide was established by
the International Headache Society and updated in 2004. It includes more than
150 diagnostic headache categories. In general, headaches are classified as:
- Migraines – episodic severe headaches with nausea and vomiting, and
sensitivity to light and noise.
- Tension, chronic daily headache or chronic non-progressive headache
-- headaches that occur daily or periodically but do not include the
migraine features listed above.
- Mixed headache syndrome – combination of migraine and chronic
nonprogressive (tension) headaches. Mixed headache syndrome is also called
chronic migraine or transformed migraine.
- Traction and inflammatory headaches - headaches that may be due to
an illness or intracranial (within the cranium or skull) disorder – for
example, a brain tumor or bleeding within the brain.
- Other – Our methods to classify headaches types – eg, by headache
onset, duration, and frequency (ie, from sudden to daily and/or frequently
occurring) are listed below:
- Acute headaches – headaches that occur suddenly for the first time
with symptoms that may subside after a relatively short period of time.
Acute headaches most commonly result in a visit to the pediatrician’s office
and/or the emergency room. Children or adolescents who go to the emergency
room with acute headaches may have migraine or tension headaches. In some
cases, the headaches may be simply due to an illness (such as the flu),
infection or fever. Other conditions that can cause an acute headache
include sinusitis (inflammation of the sinuses), pharyngitis (inflammation
or infection of the throat) or otitis (ear infection or inflammation).
Acute headaches can also be the result of a blow to the
head (trauma) or rarely may be a sign of a more serious medical
condition, such as meningitis (an infection or inflammation of the
membrane that covers the brain and spinal cord), encephalitis
(inflammation of the brain), hemorrhage (bleeding within the brain) or
tumor. Children and adolescents with these problems usually have
neurological symptoms (including stiff neck, seizures) and have other
signs of illness on the physical exam in addition to the headaches.
Acute recurrent headaches or migraines – migraine is a
moderate-to-severe headache with symptoms that last from 1 to 4 hours and
usually occurs 2 to 4 times per month. The pain is often throbbing and on
one or both sides of the head. Common symptoms of migraine in children and
adolescents include pallor, nausea and vomiting and irritability. The child
may also be very sensitive to light, noise or smells and want to sleep.
- Chronic nonprogressive headaches or tension headaches – daily or
frequent headaches or headaches that come and go over a prolonged period of
time without causing neurological symptoms. Common causes include stress,
tension and depression. This is the most common type of headache in
adolescents. Common associated features include dizziness and fatigue.
- Chronic progressive headaches
headaches that get worse and happen
more often over time. These are the least common type of headache. When
chronic progressive headaches occur along with other neurological symptoms
(for example, weakness, balance problems and visual disturbances), they can
be the sign of a disease process in the brain (organic cause) such as
hydrocephalus (abnormal build-up of fluid in the brain), infection of the
brain, tumor or other conditions.
How are headaches evaluated and diagnosed in children and adolescents?
The correct headache diagnosis is needed to develop an effective treatment plan.
The most important aspect of the headache
evaluation is the headache history, which should be obtained from both the child
and his or her parents. It is important to describe headache symptoms and
characteristics as completely as possible so the headaches can be properly
diagnosed and successfully treated. Your headaches can be properly diagnosed if
your doctor knows:
- How the headaches started
- When the headaches started
- How long the headaches have been present
- Whether there is a single type of headache or multiple types of headaches
- How often the headaches occur and if they are becoming more frequent
- What causes the headaches, if known (for example, do certain situations,
foods, or medications usually trigger the headache)
- If physical activity aggravates the headache pain
- What other symptoms are associated with the headache (for example,
weakness, visual change, loss of consciousness)
- Who else in your family has headaches
- What symptoms, if any, occur between headaches
Your doctor will also ask additional questions about performance
in school, family background and history of substance abuse.
Clinical description of headaches.
The patient will be asked
to describe how he or she feels when a headache occurs. Questions that will be
asked will include:
- Where the pain is located
- What it feels like
- How severe the headache pain is, using a scale from 1 (mild) to 10 (severe)
- If the headaches appear suddenly without warning or with accompanying symptoms
- What time of day the headache usually occurs
- If there is an aura (changes in vision, blind spots or bright lights) before the headache
- What other symptoms occur with a headache (weakness, nausea, sensitivity
to light or noise, decreased appetite, changes in attitude or behavior)
- How long the headache lasts
History of headache treatments.
Patients should be able to
provide a history of prior headache treatments. Tell your doctor what
medications you have taken in the past, what medications you are currently
taking, and which medications worked best for you. Don’t hesitate to list them,
bring the medication bottles to the office appointment, or ask your pharmacist
for a printout.
If any studies or tests were previously performed, bring the
results with you. This may save time and avoid repetition of tests.
Physical and Neurological Examinations. After completing the
medical history part of the evaluation, your doctor will perform physical and
neurological examinations. The doctor will look for signs of an illness that may
be causing the headache. These signs may include: fever, high blood pressure,
muscle weakness, balance problems, or vision problems.
After evaluating the results of the headache history, physical
examination and neurological examination, your doctor should be able to
determine what type of headache you have, whether or not a serious problem is
present, and if additional tests are needed.
When additional tests may be needed.
If the headache history
or physical exam results suggest a condition within the brain as the cause of
the headaches (organic cause), additional laboratory tests may be needed.
A MRI scan (magnetic resonance imaging) and a MRA scan (magnetic
resonance imaging of the arteries) are two types of tests your doctor may order
to help determine if a serious medical problem is the cause of the headaches.
Both of these imaging tests allow the tissues and arteries within the brain to
be seen and evaluated.
A CT scan is not as detailed as an MRI scan but is often used as
a screening test in the emergency room.
Skull X-rays are not helpful. An electroencephalogram (EEG) is
usually unnecessary unless the child has lost consciousness with his or her headaches.
If stress or school issues might be the cause of headache, a
psychological evaluation is often necessary and helpful.
Although additional tests may be important to ensure that the
headaches are not the result of a serious medical condition, they do not help in
diagnosing migraine, cluster, or tension-type headaches.
How are headaches treated in children and adolescents?
The proper treatment will depend on several factors, including
the type and frequency of the headache, its cause and the age of the child.
Treatment may include education, stress management, biofeedback and medications.
Patient education includes learning
about your headache type and recording what triggers the headaches, such as lack
of sleep, a poor diet, degree of disability, your environment, or stress. Your
doctor may give you a Headache Diary to record the characteristics of your
headaches and will recommend ways of managing the headache triggers. Bring this
diary with you to all of your doctor appointments; this information will help
your doctor correctly treat your headaches.
Learning relaxation techniques can
help modify the pain and/or frequency of the headaches. If you have a headache,
- Lie down and relax
- Stretch and relax your muscles
- Apply a cold compress to your head
- Take a hot shower
- Take breaks from activities that trigger or provoke headaches, such as
using the computer for long periods of time, studying, or exercising strenuously
Other ways to relax or reduce stress include:
- Deep breathing exercises
- Progressive muscle relaxation
- Mental imagery relaxation
- Relaxation to music
- Biofeedback (explained in next section)
- Counseling (can help patients recognize and relieve stress)
Biofeedback helps a person learn
stress-reduction skills by providing information about muscle tension, heart
rate, and other vital signs as a person attempts to relax. It is used to gain
control over certain bodily functions that cause tension and physical pain.
Biofeedback can be used to help you learn how your body responds
in stressful situations, and how to better cope. If a headache, such as a
migraine, begins slowly, many people can use biofeedback to stop the attack
before it becomes full blown.
Medications may be recommended to manage
headache pain. Headache medications can be grouped into three different
categories: symptomatic relief, abortive therapy and preventive therapy. Each
type of medication is most effective when used in combination with other
recommendations, such as dietary and lifestyle changes, exercise and relaxation
therapy. In some patients, drugs from one or more of the three categories are
- Symptomatic relief — used to relieve symptoms associated with
headaches, including the pain of a headache or the nausea and vomiting
associated with migraine. These may include simple analgesics such as
ibuprofen or acetaminophen, antiemetics (for nausea/vomiting) or sedatives
(to help sleep; sleep relieves headaches). Some of these are available
without a prescription (over-the-counter), while others require a
prescription from your doctor.
Important: if symptomatic relief medications are
used more than twice a week, see your doctor. Overuse of symptomatic
medications can actually cause more frequent headaches or worsen
headache symptoms. If this is the case, your doctor may want to
prescribe preventive headache medications instead.
- Abortive therapy — used at the first sign of a migraine to stop the
process that causes the headache pain. By stopping the headache process,
abortive medications help prevent the symptoms of migraines including pain,
nausea, light-sensitivity, etc. Abortive medications include: the
nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen);
acetaminophen; the triptans -- sumatriptan (Imitrex®),
zolmitriptan (Zomig®), rizatriptan (Maxalt®),
almotriptan (Axert®), eletriptan (Relpax®), and the
longer-acting triptans frovatriptan (Frova®) and naratriptan (Amerge®);
ergotamine tartrate and caffeine (Cafergot®); and
dihydroergotamine mesylate (DHE-45®, Migranal®). These
medications require a prescription.
- Preventive therapy — used to treat very frequent tension headaches
or migraines, or the combination of both types of headaches. Preventive
therapy relies on taking a daily dose of a medication to reduce both the
frequency and severity of the headache. Medications commonly prescribed as
preventive therapy include: antidepressants, antihistamines, beta blockers,
calcium channel blockers, or anticonvulsants. Most of these medications
require a prescription and take 4 to 6 weeks to reach their maximum
What happens next?
When your doctor starts a treatment program, keep track of how
well the program is working for you. Keep your scheduled follow-up appointments
so that your doctor can monitor your progress and adjust your treatment program
Do children outgrow headaches?
As a child grows, headaches may disappear; however, they may
return later in life. Migraines can go away as soon as a year after they first
appear, even without treatment, or they may recur throughout a patient’s life.
Headache ‘checklist’ of management suggestions
- Educate yourself and your family. Read about your type of headache and its treatment.
- Maintain a headache diary.
- Ask your doctor for written instructions about what to do when you have a headache.
- Limit your use of over-the-counter (nonprescription) medications to no more than two days per week. Excessive use can actually increase headaches.
- Follow a regular schedule:
- Don’t skip meals, especially breakfast
- Get 8 hours of sleep nightly
- Exercise 30 minutes/day
- Drink 6 to 8 glasses of water/day
- Learn to identify and avoid headache "triggers." Common triggers include
caffeinated foods and beverages (chocolate, teas, colas, coffee), nitrates
(luncheon meats, sausage/hot dogs, pepperoni), tyramine (aged cheeses,
pizza), Doritos®, Ramen® noodles, other "junk" foods,
and Oriental foods containing MSG
- Minimize stress and other headache triggers
- Daily school attendance IS A MUST!
- Initiate non-drug measures at the earliest onset of your headache:
- Seek rest in a cool, dark, quiet, comfortable location
- Use relaxation strategies and other methods to reduce stress
- Apply a cold compress
- Don’t wait!! Take the maximum allowable dosage of recommended
medication(s) at the first sign of a severe headache.
- Take prescribed medication regularly, as directed, and maintain regular follow-up visits.
- Call your doctor when problems arise.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 8/1/2009…#4225