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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.

Headache history.

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.

Headache education.

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.

Relaxation techniques.

Learning relaxation techniques can help modify the pain and/or frequency of the headaches. If you have a headache, you should:

  • 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 used simultaneously.

  • 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 effectiveness.

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 if necessary.

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

  1. Educate yourself and your family. Read about your type of headache and its treatment.
  2. Maintain a headache diary.
  3. Ask your doctor for written instructions about what to do when you have a headache.
  4. Limit your use of over-the-counter (nonprescription) medications to no more than two days per week. Excessive use can actually increase headaches.
  5. Follow a regular schedule:
    1. Don’t skip meals, especially breakfast
    2. Get 8 hours of sleep nightly
    3. Exercise 30 minutes/day
    4. Drink 6 to 8 glasses of water/day
    5. 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
    6. Minimize stress and other headache triggers
  6. Daily school attendance IS A MUST!
  7. Initiate non-drug measures at the earliest onset of your headache:
    1. Seek rest in a cool, dark, quiet, comfortable location
    2. Use relaxation strategies and other methods to reduce stress
    3. Apply a cold compress
  8. Don’t wait!! Take the maximum allowable dosage of recommended medication(s) at the first sign of a severe headache.
  9. Take prescribed medication regularly, as directed, and maintain regular follow-up visits.
  10. Call your doctor when problems arise.

© Copyright 1995-2009 The Cleveland Clinic Foundation. All rights reserved.

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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