Informational Podcasts
Headaches are among the most problems encountered in adolescents; up to 30 percent of adolescents experience frequent migraine or tension headaches and half of those destined to suffer from migraines experience their first migraine before they turn 18. Listen to free audio files from Cleveland Clinic about headaches in children and adolescents.
Overview of Headaches in Children and Adolescents
Kids get headaches, too! Many adults with headaches started having them as kids – in fact 20% of adult headache sufferers say their headaches started before age 10, and 50% report their headaches started before age 20.
How Common Are Headaches in Children and Adolescents?
Headaches are very common in children and adolescents. In one study, 56 percent of boys and 74 percent of girls between the ages of 12 and 17 reported having had a headache within the past month. By age 15, 5 percent of all children and adolescents have had migraines and 15 percent have had frequent non-progressive or tension-type headaches.
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 not the result of a serious illness. When to worry about your child's headaches.
What Are the Common Types of Headaches in Children and Adolescents?
A comprehensive headache classification guide was established by the International Headache Society and includes more than 150 diagnostic headache categories.
Based on research, a practical headache classification includes primary and secondary headaches. The Cleveland Clinic classification of headaches in children and adolescents is included below.
Primary Headaches
Primary headaches are those headaches that are not the result of another medical condition. They include:
Acute recurrent headaches or migraines — a migraine is a moderate to severe headache that lasts from 1 to 24 hours and usually occurs 2 to 4 times per month. The pain is often throbbing and affects the front or both sides of the head. Common symptoms of migraines in children and adolescents include paleness (pallor), decreased appetite, dizziness, blurred vision, fever, stomach upset, nausea and vomiting. The child may also be very sensitive to light, noise or smells and want to sleep.
A small percentage of pediatric migraines include “cyclic” or recurrent gastrointestinal symptoms of which vomiting is most common. Cyclic vomiting means that the symptoms occur on a regular basis – about once a month. These types of migraines are sometimes called abdominal migraines.
Chronic nonprogressive headaches or tension-type headaches — frequent or daily headaches or headaches that come and go over a prolonged period of time without causing neurological symptoms. These are the most common types of headache among adolescents. About 15% of children and adolescents suffer from tension-type headaches.
Secondary Headaches
Secondary headaches are those headaches that result from another medical condition. They include the following:
Acute headaches — headaches that occur suddenly for the first time with symptoms which 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. If there are no neurological signs or symptoms, the most common cause for acute headaches in children and adolescents is a respiratory or sinus infection.
Chronic progressive headaches — headaches that get worse and happen more often over time. These are the least common types of headache, accounting for less than 2% of all children’s headaches, according to the National Headache Foundation.
What Causes Headaches in Children and Adolescents?
Acute headaches are usually due to an illness, infection, cold 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).
Children or adolescents who go to the emergency room with acute headaches may have migraine or tension-type headaches. In some cases, the headaches may be the result of a blow to the head (trauma) or rarely, the sign of a more serious medical condition.
The exact causes of acute recurrent headaches or migraines are unknown, although they are related to changes in the brain as well as to genetic causes. For many years, scientists believed that migraines were linked to the expanding (dilation) and constriction (narrowing) of blood vessels on the brain’s surface. However, it is now believed that migraines are caused by inherited abnormalities in certain areas of the brain.
There is a migraine “pain center” or generator in the mid-brain area. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing constriction, followed by the dilation of these vessels and the release of prostaglandins, serotonin and other inflammatory substances that cause the pulsation to be painful.
Most children and adolescents (90%) who have migraines have a family history of migraines. When both parents have a history of migraines, there is a 70% chance that the child will also develop migraines. If only one parent has a history of migraines, the risk drops to 25% to 50%. Children and adolescents with migraines may also inherit the tendency to be affected by certain migraine triggers, such as fatigue, bright lights, weather changes and other triggers.
Some migraine triggers can be identified such as stress, anxiety, depression, a change in routine or sleep pattern, bright light, loud noises or certain foods, food additives and beverages. Too much physical activity or too much sun can trigger a migraine in some children or adolescents.
Common causes of chronic nonprogressive headaches or tension-type headaches include striving for academic excellence as well as emotional stress related to family, school or friends; tension and depression.
Other causes of tension-type headaches include eye strain and neck or back strain due to poor posture.
When chronic progressive headaches worsen over time and occur along with other neurological symptoms, 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
- 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)
- Tumor
- Blood clots
- Head trauma
- Abscess
How Are Headaches Evaluated and Diagnosed in Children and Adolescents?
The good news for pediatric and adolescent headache sufferers is that once a correct headache diagnosis is made, an effective treatment plan can be started.
If your child has headache symptoms, the first step is to take your child to his or her family physician. The family physician will perform a complete physical examination and a headache evaluation. During the headache evaluation, your child’s headache history and description of the headaches will be evaluated. You and your child will be asked to describe the headache symptoms and characteristics as completely as possible.
A headache evaluation may include a CT scan or MRI if a structural disorder of the central nervous system is suspected. Both of these tests produce cross-sectional images of the brain that can reveal abnormal areas or problems. Skull X-rays are not helpful. An EEG (electroencephalogram) is also unnecessary unless the child has lost consciousness or has abnormal muscle contractions or other abnormal symptoms with a headache.
If your child’s headache symptoms become worse or become more frequent despite treatment, ask your family physician for a referral to a specialist. Children should be referred to a pediatric neurologist, and adolescents should be referred to a headache specialist. Your family physician should be able to provide the names of headache specialists. If you need more information, contact one of the organizations in the resource list for list of member physicians in your state.
How Are Headaches Treated in Children and Adolescents?
The family physician may recommend different types of treatment to try. You should establish a reasonable time frame with the family physician to evaluate your child’s headache symptoms.
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
Headache education includes identifying and recording what triggers your child’s headache, such as lack of sleep, not eating at regular times, eating certain foods or additives, caffeine, environment or stress. Helping your child keep a headache diary can help you and your child record this information. Avoiding headache triggers is an important step in successfully treating the headaches.
Stress Management
To successfully treat tension-type headaches, it is important for kids and their parents to identify what causes or triggers the headaches. Then they can learn ways to cope or remove the stressful activities or events.
Biofeedback
Biofeedback equipment includes sensors connected to the body to monitor your child’s involuntary physical responses to headaches, such as breathing, pulse, heart rate, temperature, muscle tension and brain activity. By learning to recognize these physical reactions and how the body responds in stressful situations, biofeedback can help your child learn how to release and control tension that causes headaches to better cope.
Medications
There are three categories of headache medications for children, including symptomatic relief, abortive and preventive medications. Many of the medications used to treat adult headaches are used in smaller doses to treat headaches in children and adolescents. Many of the medications used to treat pediatric headaches have not been specifically approved for use in children. However, research is ongoing to study the effects of these headache medications on children.
Aspirin should not be used to treat headaches in children under age 15 to reduce the risk of Reye’s syndrome, a rare disorder that kids get when they are recovering from childhood infections such as chicken pox or the flu.
What Happens After My Child Starts Treatment?
When your child’s physician starts a treatment program, keep track of the results by using a headache diary, and record how the treatment program is working. Keep your child’s scheduled follow-up appointments so your child’s doctor can monitor your child’s progress and make changes in the treatment program as needed.
Do Children Outgrow Headaches?
Headaches may improve as your child gets older. The headaches may disappear and then return later in life. By junior high school, many boys who have migraines outgrow them, but in girls, migraine frequency increases because of hormone changes. Migraines in adolescent girls are three times more likely to occur than in boys.
Migraines in Children and Adolescents
A migraine headache is considered a vascular headache because it is associated with changes in the size of the arteries within and outside of the brain.
For many years it was thought that migraine was primarily a disorder of the blood vessels. We now know that migraine is a genetic disorder that is inherited. Four out of 5 migraine sufferers have a family history of migraines. If one parent has a history of migraines, the child has a 50% chance of developing migraines, and if both parents have a history of migraines, the risk jumps to 75%.
How common are migraines among children and adolescents?
Migraines affect about 1.5 percent of children by age 7 and about 5 percent of children and adolescents by age 15. Disability from headaches can be significant with many days lost from school or play.
In early childhood and before puberty, migraines are more frequent among boys. In adolescence, migraines affect young women more than young men. As adults, women are three times more likely to suffer from migraines than men.
What causes migraines?
The exact causes of migraines are unknown, although they are related to changes in the brain as well as to genetic causes. People with migraines may inherit the tendency to be affected by certain migraine triggers, such as fatigue, bright lights, weather changes and others.
For many years, scientists believed that migraines were linked to the expanding (dilation) and constriction (narrowing) of blood vessels on the brain’s surface. However, it is now believed that migraine is caused by inherited abnormalities in certain areas of the brain.
There is a migraine “pain center” or generator in the mid-brain area. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing constriction, followed by the dilation of these vessels and the release of prostaglandins, serotonin and other inflammatory substances that cause the pulsation to be painful.
Certain brain cells that use serotonin as a messenger are involved in controlling mood, attention, sleep and pain. Therefore, chronic changes in serotonin can lead to anxiety, panic disorder and depression.
What are some migraine triggers?
In many children and adolescents, migraines are triggered by external factors. These “triggers” vary for each person. Some common migraine triggers include:
Emotional Stress
Emotional stress is one of the most common triggers of migraine headache. Migraine sufferers are generally found to be highly affected by stressful events. During stressful events, certain chemicals in the brain are released to combat the situation (know as the “flight or fight” response). The release of these chemicals can provoke vascular changes that can cause migraine. Repressed emotions surrounding stress, such as anxiety, worry, excitement and fatigue can increase muscle tension and dilated blood vessels can intensify the severity of migraine.
Carefully reviewing what causes stress can help you determine what stress factors you can avoid. Stress management includes regular exercise, adequate rest and diet, and promoting pleasant activities such as enjoyable hobbies.
Ovulation or Menstruation
Normal hormonal changes caused by ovulation and menstrual cycles can trigger migraines.
Changes in Normal Eating Patterns
Skipping meals lowers the body’s blood sugar and can cause migraines. Eating three regular meals and not skipping breakfast can help.
Caffeine
Excessive caffeine consumption or withdrawal from caffeine can cause headaches when the caffeine level abruptly drops. The blood vessels seem to become sensitized to caffeine, and when caffeine is not ingested, a headache may occur. If you are trying to cut back on caffeine, do so gradually. Caffeine itself is often helpful in treating acute migraine attacks.
Weather Changes
Weather changes such as storm fronts, barometric pressure changes, strong winds or changes in altitude can trigger migraines.
Medications
Some medications, such as oral contraceptives (birth control pills), and asthma treatments may trigger a migraine. Ask your health care provider if there are other alternatives to these medications.
Sensitivity to Specific Chemicals and Preservatives in Foods
Certain foods and beverages, such as aged cheese, alcoholic beverages, and food additives such as nitrates (in bacon, pepperoni, hot dogs, luncheon meats), phenylethylamine in chocolate and monosodium glutamate (MSG, commonly found in Chinese food) may be responsible for triggering up to 30% of migraines. These foods dilate blood vessels, causing a pain message to be sent back to the brain. Recalling what was eaten prior to a migraine attack may help you identify certain foods that are potential triggers so you can avoid them in the future.
Changes in Regular Routine
Personal routine changes such as lack of sleep, travel, riding in a car or illness can cause migraines. Exercising regularly and getting adequate rest can decrease the number of migraine attacks.
What are the types of migraine in children and adolescents?
Common Migraine or Migraine Without Aura*
This is the most frequent type of migraine in children and adolescents, making up about 80 to 85 percent of all migraines.
Classic Migraine or Migraine with Aura*
Less frequent than common migraine, classic migraine makes up about 15 to 20 percent of all migraines. In young children, classic migraine often begins in the late afternoon. As the child gets older, the onset of migraine may change to early morning.
*Aura is a warning sign that a migraine is about to begin. An aura usually occurs about 10 to 30 minutes before the onset of a migraine. The most common auras are visual and include blurred or distorted vision; blind spots; or brightly colored, flashing or moving lights or lines. Other auras may include speech disturbances, motor weakness or sensory changes. The duration of an aura varies, but it generally lasts less than 20 minutes.
Complicated migraine syndromes are associated with neurological symptoms, including:
- A stroke-like weakness on one side of the body, associated with hemiplegic migraine
- Drooping eyelid and dilated pupil, associated with ophthalmoplegic migraine
- Pain at the base of the skull with numbness, visual changes and balance difficulties associated with basilar artery migraine
- A temporary period of confusion often initiated by minor head injury, associated with confusional migraine
Patients with complicated migraine syndromes require a complete neurological evaluation, which may include a magnetic resonance imaging (MRI) scan. Most patients with complicated migraine recover completely, and a structural abnormality is rarely the cause.
Migraine variants are disorders that cause periodic symptoms that come and go. Migraine variants include:
- Paroxysmal vertigo — dizziness that is marked by sudden, intense symptoms
- Paroxysmal torticollis — sudden contraction of one side of the neck muscles that causes the head to lean to that side
- Cyclic vomiting — uncontrolled vomiting that occurs repeatedly over a certain period of time
The key to diagnosing these migraine variants, which can be confused with other neurological syndromes, is their tendency to recur at intervals. The person does not have symptoms in between attacks.
What are the symptoms of migraine?
The symptoms of migraine headaches can occur in various combinations and include:
Type of Pain
The pain of a migraine can be described as a pounding or throbbing. The headache often begins as a dull ache and develops into throbbing pain. The pain is usually aggravated by physical activity.
Severity/Intensity of Pain
The pain of a migraine can be described as mild, moderate or severe.
Location of Pain
In children and adolescents, the pain usually affects the front or both sides of the head. In adults, the pain usually affects one side of the head.
Duration of Pain
Most migraines last about 4 hours although severe ones can last up to a week.
Frequency of Headaches
The frequency of migraines varies widely among individuals. It is common for a migraine sufferer to get 2-4 headaches per month. Some people, however, may get headaches every few days, while others only get a migraine once or twice a year.
Associated Symptoms
- Sensitivity to light, noise and odors
- Nausea and vomiting, stomach upset, abdominal pain
- Loss of appetite
- Sensations of being very warm or cold
- Paleness (pallor)
- Fatigue
- Dizziness
- Blurred vision
- Diarrhea (rare)
- Fever (rare)
How are migraines diagnosed?
The correct headache diagnosis is needed to begin an effective treatment plan. The most important aspect of the headache evaluation is the headache history which should be obtained from both the patient and his or her parents.
The history includes the clinical description of headaches in which the patient describes how he or she feels with the headache and what happens when a headache occurs.
A history of prior headache treatments is also an important part of the headache evaluation, including what medications have been taken in the past and what medications are currently being taken. If any studies or tests were previously performed, it is important to bring them with you to the headache evaluation.
After completing the medical history part of the evaluation, your physician will perform physical and neurological examinations.
After evaluating the results of the headache history, physical examination and neurological examination, the physician should be able to determine what type of headache you have, whether or not a serious problem is present and whether additional tests are needed.
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 patient/parent education, stress management, biofeedback and medications.
Headache Education
Education includes reviewing information about the type of headaches, learning and recording what triggers the headaches (such as lack of sleep, a poor diet, environment or stress), and how to use medicine safely and appropriately. Your health-care provider will give you a “headache diary” to record the characteristics of the headaches and will recommend ways of managing the headache triggers. Bring this diary to all doctor appointments; this information will help your health care providers correctly treat your child’s headaches.
Relaxation Techniques
Learning relaxation techniques can help reduce headaches. If your child has a headache, he or she should lie down and relax, and stretch and relax the muscles. Also, the child should take breaks from activities that trigger or provoke headaches, such as using the computer for long periods of time or exercising strenuously.
Medications
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 medical recommendations, such as dietary and lifestyle changes, exercise and relaxation therapy.
Symptomatic Relief
Symptomatic relief is 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, ibuprofen or acetaminophen, antiemetics or sedatives. Many of these are available without a prescription (over the counter), while others require a prescription from your health-care provider. Important: If symptomatic relief medications are used more than twice a week, you should see your health care provider who can prescribe preventive headache medications. Overuse of these symptomatic medications can actually cause more frequent headaches or worsen headache symptoms.
Abortive Therapy
Abortive therapy medications are most effective when 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: ergotamine tartrate and caffeine (Cafergot), dihydro-ergotamine mesylate (DHE-45), a combination medication (Midrin), and triptans.
Preventive Therapy (prophylactics)
Prophylactic medications are used to treat very frequent tension-type headaches and migraines. Preventive therapy is aimed at reducing both the frequency and severity of the headaches and includes nonsteroidal anti-inflammatory (NSAID) medications, antidepressants, antihistamines, beta blockers, calcium channel blockers and anticonvulsant medications as recommended by your doctor. Most of these medications require a prescription.
How are migraines treated in young children?
To treat infrequent migraine attacks in young children, these symptomatic medications are useful:
- Simple analgesics — pain reliever medications such as acetaminophen or ibuprofen, but not aspirin
- Antiemetics — medications that relieve nausea and vomiting
- Sedatives — medications that help a child rest
To treat very frequent attacks in young children, these preventive medications may be prescribed:
- Cyproheptadine, propranolol, tricyclics or calcium-channel blockers
- Anticonvulsants are not generally recommended
How are migraines treated in adolescents?
To treat infrequent migraine attacks in adolescents (with or without aura), the following abortive and symptomatic medications can be useful:
- Analgesics — pain reliever medications
- Antiemetics — medications that relieve nausea and vomiting
- Sedatives — medication that helps a patient rest
To treat infrequent migraine attacks in adolescents (if an aura is not present), the following abortive medications can be prescribed:
- Ergotamine tartrate and caffeine (Cafergot)
- A combination medication (Midrin)
- Triptans (Imitrex, Zomig, Amerge and Maxalt)
To treat severe migraine attacks in adolescents, the following abortive medications can be prescribed:
- Triptans nasally, orally or by injection
- DHE45
In adolescents with frequent attacks and when the above medications have been unsuccessful, preventive medications such as propranolol, tricyclic antidepressants or calcium-channel blockers or anticonvulsants may be prescribed.
Please note: many of the medications listed previously have not been approved by the FDA for use in children and adolescents with headaches.
How can migraines be prevented?
Identifying and then avoiding migraine triggers should reduce the frequency of your migraine attacks.
Recalling what was eaten prior to an attack may help you identify chemical triggers and make the necessary dietary changes to avoid these triggers in the future.
Young women who get migraines during their menstrual periods should become aware of the menstrual cycle patterns as they relate to the onset of the headaches to help them take preventive action against the headaches. Hormonal treatment of migraines has not been satisfactory, however.
Stress management and coping techniques, along with relaxation training, can help prevent or reduce the severity of the migraine attacks.
Migraine sufferers also seem to have fewer attacks when they eat on a regular schedule and get adequate rest.
Regular exercise – in moderation – can also help prevent migraines.
What is the outlook for children and adolescents with migraine?
Migraines can go away as soon as a year after they first appear, or they may remain for life. Treatment helps the majority of children and adolescents with migraines. Fifty percent of children and adolescents report migraine improvement within 6 months after treatment. About 60 percent of adolescent-onset migraines continue off and on for many years.
When to Worry About Your Child’s Headaches
Fortunately, less than 2% of pediatric and adolescent headaches are the result of a serious disease or physical problem.
When should a more serious problem be considered?
Medical History
A more serious problem should be considered when your child’s general medical or neurological history reveal any of the following:
- New headaches that have been occurring for less than 6 months, are worsening and do not improve after treatment
- Progressive headaches: headaches that are becoming more severe and frequent over time
- No family history of similar headaches
- A family history of neurological disease
Physical Exam
A more serious problem should be considered when your child’s physical exam reveals any of the following:
- Abnormalities of temperature, breathing, pulse or blood pressure
- Inflammation of the optic nerve, the nerve in the back of the eye
- An enlarged head
- A noise or bruit in the head heard through a stethoscope
- Coffee-colored spots on the skin
Neurological Symptoms
A more serious problem should be considered when your child has any of these neurological symptoms:
- Nausea or vomiting
- Weakness
- Dizziness
- Sudden loss of balance or falling
- Numbness or tingling
- Paralysis
- Speech difficulties
- Mental confusion
- Seizures
- Loss of consciousness
- Personality changes/inappropriate behavior
- Vision changes (blurry vision, double vision or blind spots)
- Lethargy: being indifferent, apathetic or sluggish, or sleeping too much
A structural disorder of the central nervous system, as listed below, may be suspected in the development of serious headaches:
- Tumor
- Abscess
- Hemorrhage (bleeding within the brain)
- Bacterial or viral meningitis (an infection or inflammation of the membrane that covers the brain and spinal cord)
- Pseudotumor cerebri (increased intracranial pressure)
- Hydrocephalus (abnormal build-up of fluid in the brain)
- Infection of the brain
- Encephalitis (inflammation of the brain)
- Blood clots
- Head trauma