Headaches in Children and Adolescents

Overview

Many parents worry that their child’s headache is a sign of a brain tumor or other serious medical condition. This is usually not the case. Stress and muscle tension or migraine cause most of the headaches seen in children and adolescents. Headaches can also occur with fever, colds, the flu, and other upper respiratory infections. However, only your doctor can evaluate your child’s headache to determine its cause.

When might a child's headache be a symptom of a more serious health problem?

A more serious problem may exist when a child’s headaches:

  • Increase in number (three or more a week), keep getting worse, or won’t go away.
  • Don’t respond to simple therapy.
  • Wake the child from sleep.
  • Are triggered by exertion, coughing, bending, or strenuous activity.
  • Occur along with balance problems, loss of muscle strength in the limbs, vision problems, dizziness, or loss of consciousness.
  • Occur along with a stiff neck or fever.
  • Occur along with projectile vomiting, blurred vision, and confusion.
  • Occur and there is no family history of similar headaches.
  • Occur and there is a family history of neurological disease.

Neurologic symptoms that may indicate a brain problem as the cause of the headache include:

  • Seizures — loss of consciousness.
  • Ataxia — loss of muscle coordination, especially of the arms and legs (for example, can’t walk, pick up objects, or maintain balance).
  • Lethargy — sluggish, sleepy, tiredness.
  • Weakness — especially on one side of the body.
  • Nausea and vomiting — especially if it occurs in the early morning or is becoming more frequent or more severe.
  • Visual problems — blurred vision, double vision, decreased vision, eye movement problems, blind spots.
  • Personality change — acting inappropriate or a change from previous behavior, feeling sad or depressed, rapid mood swings from happy to sad or sad to happy.
  • Slurred speech or numbness/tingling.

Other signs of a more serious health problem:

  • Abnormal temperature, breathing, pulse, or blood pressure.
  • Swelling (inflammation) of the optic nerve (this condition is also called papilledema). (The optic nerve is the nerve in the back of the eye.)
  • An enlarged head.
  • A noise, called a bruit, in the head heard through a stethoscope.
  • Coffee-colored spots on the skin.
  • An abnormal neurological exam.

How common are headaches in children and adolescents?

Headaches are common in children and adolescents. Among children ages 5 to 17 years of age, 20% have reported getting headaches. The most common types of headaches in this age group are tension headaches (reported by 15%) and migraine (reported by 5%). Many parents worry that their child’s headache is the sign of a brain tumor or serious medical condition. However, less than 3% of headaches are the result of these conditions. Many headaches in children and adolescents are the result of stress and lifestyle issues.

What types of headaches are seen in children and adolescents?

The International Headache Society lists more than 150 headache types. In general, headaches are broken down into four main categories:

  • Migraine. These are episodic (occurs a few times a month) severe headaches with sensitivity to light and noise followed by nausea and vomiting. Migraine can be hereditary. About 60% of people who have a migraine also have an immediate family member (mother, father, sister, brother) who have migraine.
  • Episodic tension (less than 15 days/month), chronic (more than 15 days/month) daily headache, or chronic non-progressive headache. These headaches occur daily or a few times a month, but patients do not experience the symptoms of migraine listed above.
  • Mixed headache syndrome. These are a combination of migraine and chronic non-progressive (tension) headaches. Mixed headache syndrome is also called chronic migraine or transformed migraine. Patients with mixed headache syndrome have headaches more than 15 days/month.
  • Traction and inflammatory headaches. These headaches may be due to an illness or brain disorder – for example, a brain tumor or bleeding within the

Cleveland Clinic classifies headaches in children and adolescents by when the headaches start, how long they last, and how often they occur. The general categories of headaches are:

  • Acute headaches. These headaches occur suddenly for the first time with symptoms that may resolve within a short period of time. Acute headaches are a common reason for visits to a pediatrician’s office and/or an emergency room. Children or adolescents who go to the emergency room with acute headaches may have migraine or tension headaches. However, there are many other conditions that may cause acute headaches. These include simple illnesses (such as flu, infection, or fever), sinusitis (inflammation of the sinuses), pharyngitis (inflammation or infection of the throat), otitis (ear infection or inflammation), or be the result of a blow to the head (trauma). In athletes, exertion may cause headaches.

In rare cases, acute headaches can 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. In addition to headaches, children and adolescents with these problems usually have neurological symptoms including stiff neck, seizures, morning vomiting, balance difficulty, vision problems, and weakness on one side of the body.

  • Acute recurrent headaches or migraines. – Migraines are moderate-to-severe headaches with symptoms that last from 1 to 4 hours and usually occurs 2 to 4 times per month. The pain is often described as throbbing and affects the front or both sides of the head. Common symptoms of migraine in children and adolescents include pale color (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. These are 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, anxiety, and depression. This is the most common type of headache in adolescents. If it occurs more than 15 days/month along with frequent school absences and medication overuse, see a headache specialist.
  • Chronic progressive headaches. These are 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 such brain conditions as an abnormal build-up of fluid in the brain (hydrocephalus), inflammation of the brain, tumor, or other conditions brain.

What known serious medical conditions can cause a headache in children?

Serious medical conditions that may cause a headache include:

  • Brain tumor
  • Abscess (infection of the brain)
  • Intracranial bleeding (bleeding within the brain)
  • Bacterial or viral meningitis (infections)
  • Hydrocephalus (excess cerebrospinal fluid in the brain)
  • Pseudotumor cerebri (increased pressure in the brain)
  • Seizure disorders
  • Trauma (injury) to the head
  • Changes in metabolic functions, such as changes in blood sugar level, sodium level, or dehydration
  • Drinking chemicals or poisons

When should I call my doctor about my child’s headache symptoms?

Contact your health care provider as soon as possible if your child has experienced ANY of the symptoms or signs mentioned above. In addition, call if your child:

  • Needs to take a pain reliever more than two or three times a week for the headaches.
  • Needs more than the recommended doses of over-the-counter (nonprescription) medications to relieve headache symptoms.
  • Misses school due to the headaches.

Diagnosis and Tests

How do doctors determine if my child’s headaches indicate a serious health problem?

First, your doctor reviews the child’s headache history. Your doctor will ask how often the headaches occur, how long they last, and any signs and symptoms that occur before, during, or after the headaches. Your doctor will also perform physical and neurological exams to look for signs of an illness that may be causing the headache.

Tests your doctor may order include a MRI scan (magnetic resonance imaging) and a MRA scan (magnetic resonance imaging of the arteries). Both imaging tests show the tissues and arteries in the brain. Skull X-rays are not helpful. Unless the child has lost consciousness while having headaches or a seizure is suspected, an EEG (electroencephalogram) is not needed. If a patient arrives at a hospital’s emergency room, a CT scan is often ordered.

How are headaches evaluated and diagnosed in children and adolescents?

Headache history. Gathering details about the headaches is key to diagnosis and for creating an effective treatment plan. The headache history should be obtained from both the child and his or her parents. Questions you will be asked include:

  • 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 triggers 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 questions about how well the child is performing at school, any history of substance abuse, and other medical problems.

Clinical description of headaches. The patient will be asked to describe how he or she feels when a headache occurs. Questions you will be asked include:

  • Where the pain is located
  • What does the pain feel like
  • How severe is the headache pain, using a scale from 1 (mild) to 10 (severe)
  • If the headaches appear suddenly without warning or with other 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
  • What makes it feel better

History of headache treatments. Patients will be asked 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.

Physical and neurologic exams. After completing the medical history, your doctor will perform physical and neurological exams. 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.

Scans and other tests. If any studies or tests were previously performed, bring the actual scans or results with you. This may save time and avoid repeating tests.

If the headache history or physical exam results suggest a condition within the brain as the cause of the headaches, additional laboratory tests may be needed. A MRI scan (magnetic resonance imaging) and a MRA scan (magnetic resonance imaging of the arteries) allow the tissues and arteries within the brain to be seen and evaluated. These imaging tests help determine if a serious medical problem is the cause of the headaches. 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 not needed unless the child has lost consciousness with his or her headaches or a seizure is suspected.

Consultation with other specialists. Your doctor may request consultation with other specialist to obtain additional information including:

  • An ophthalmologist for unusual vision issues
  • An ENT (ears, nose, throat) specialist for balance problems
  • A gastroenterologist for associated stomach issues
  • Psychologist/psychiatrist when stress or emotional issues are of concern

Management and Treatment

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 headache education, lifestyle changes, stress management, and medications.

Headache education. Patient education includes learning about your headache type and recording what triggers the headaches, such as lack of sleep, specific foods and beverages, or stress. Common food and beverage triggers include caffeinated foods and beverages (teas, colas, coffee), chocolate, nitrates/nitrites (luncheon meats, bacon, ham, salami, sausage/hot dogs, pepperoni), aged cheeses (tyramine-containing foods; do not eat pizza), and monosodium glutamate (MSG)-containing foods (Doritos®, Ramen® noodles, other Oriental foods).

Your doctor may give you a headache diary to record your headache experiences. After reviewing your diary, your doctor will recommend ways to manage your headache triggers. Bring this diary with you to all of your appointments.

Lifestyle changes. Many headaches are related to poor lifestyle habits. Important basics to headache management are to get 8 hours of sleep a night, drink six 8-oz glasses of water day, eat three healthy meals a day (especially don’t skip breakfast), limit the use of over-the-counter medications – 2 days/week or less, and get cardio exercise (45 minutes, three times a week).

Relaxation techniques. Learning relaxation techniques can help reduce 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
  • Counseling (can help patients recognize and relieve stress)
  • Biofeedback (explained below)

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. If a headache, such as a migraine, begins slowly, many people can use biofeedback to stop the attack before it becomes full blown.

Medications. Headache medications can be grouped according to their goal: 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, or exercise and relaxation therapy. In some patients, drugs from one or more of the three categories are used together.

Symptomatic relief. These medications relieve headaches symptoms including the pain of a headache or the nausea and vomiting associated with migraine. These may include simple analgesics such as ibuprofen (Advil®, Motrin®), naproxen (Aleve®) or acetaminophen, anti-emetics (for nausea/vomiting) or sedatives (to help sleep; sleep relieves headaches). Some of these medications are available without a prescription (over-the-counter); others require a prescription from your doctor. Avoid combination products containing aspirin and caffeine; avoid barbiturates and narcotics. Some non-drug relief methods include applying a cold compress to your head or lying down in a cool, dark and quiet room.

Important: if symptomatic relief medications are used more than twice a week, see your doctor. Overuse of these medications can actually cause more frequent headaches or worsen symptoms. This condition is called rebound headaches or medication overuse headaches. If this is the case, your doctor may want to prescribe preventive headache medications instead.

Abortive therapy. These medications are 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 such as pain, nausea, and light-sensitivity. Abortive medications include the nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen); acetaminophen; and the triptans – sumatriptan (Imitrex®), zolmitriptan (Zomig®), rizatriptan (Maxalt®), almotriptan (Axert®), eletriptan (Relpax®), and the longer-acting triptans frovatriptan (Frova®) and naratriptan (Amerge®). These medications require a prescription. Some of these medications are prescribed “off label,” meaning that although they are FDA approved for use in adults, they are not approved for use in children and adolescents.

Preventive therapy. These medications attempt to prevent 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 full effectiveness. Nutraceuticals are vitamins and minerals that have proven benefit in preventing headache. These products include magnesium, riboflavin, vitamin B2, coenzyme Q10. To read more about these products, search for the document, “Relaxation and Other Alternative Approaches for Managing Headaches.”

What happens next?

Once you begin your treatment program, take your medications as directed and keep track of how well it’s working for you. Also reduce headache triggers by making any needed lifestyle changes. Finally, keep your scheduled follow-up appointments so that your doctor can monitor your progress and adjust your treatment program if necessary.

Outlook / Prognosis

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.

Living With

What is the best way to manage headaches in children and adolescents?

Suggestions for managing headaches include:

  • Educate yourself and your family. Read about your type of headache and its treatment.
  • Keep a headache diary. Bring the diary with you to your appointments.
  • Ask your doctor for written instructions about how to manage your headache.
  • Follow a regular schedule:
    • Don’t skip meals, especially breakfast.
    • Get 8 hours of sleep nightly.
    • Exercise 30 to 60 minutes three times/week
    • Drink 6 to 8 glasses of water/day`
  • Avoid your headache “triggers.” Common triggers include caffeinated foods and beverages (chocolate, teas, colas, coffee), nitrates (luncheon meats, sausage/hot dogs, pepperoni), tyramine (aged cheeses, pizza). Also avoid MSG-containing foods including Doritos®, Ramen® noodles, other “junk” foods, and Oriental foods.
  • Reduce emotional and physical stress. Take time to relax and get away from stressful situations. Learn relaxation skills, such as deep breathing, yoga, meditation, and progressive muscle relaxation. If you sit for long periods of time, get up and stretch from time to time. Relax your jaw, neck, and shoulders. Talk to a friend, family member, religious professional or health care professional if your problems are causing you stress.
  • Go to school every day. Attendance IS A MUST!
  • Start non-drug measures as soon as the headache begins:
    • Rest in a cool, dark, quiet, comfortable place.
    • Use methods to relax and reduce stress.
    • Apply a cold compress (a fabric wrapped cold pack) to your head.
  • Don't wait!! Take the highest allowable dose of recommended medication(s) at the first sign of a severe headache.
  • Take prescribed medication on schedule and as directed. Do not take medications that have not been ordered by your doctor.
  • Do not use over-the-counter (nonprescription) medications more than two doses per week. Overuse can actually increase the number of headaches.
  • Never miss a follow-up appointment with your doctor.
  • Call your doctor if problems develop.

Last reviewed by a Cleveland Clinic medical professional on 08/25/2017.

References

  • Cleves C, Rothner AD. Headache in Children and Adolescents: Evaluation and Diagnosis, including Migraine and its Subtypes. Chapter 6. In: Tepper SJ, Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. New York: Springer 2011:81-92.
  • Cleves C, Rothner AD. Diagnosis of Childhood Periodic Syndromes, Tension-Type Headaches, and Daily Headache Syndromes. Chapter 7. In: Tepper SJ, Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. New York: Springer 2011:93-103.
  • Rothner AD. Treatment of Pediatric and Adolescent Headaches. Chapter 15. In: Tepper SJ, Tepper DE, eds. The Cleveland Clinic Manual of Headache Therapy. New York: Springer 2011:209-24.
  • National Headache Foundation. Children’s Headache Disorders. (https://www.headaches.org/headaches-in-children/) Accessed 3/27/2017.

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