Headaches in Children: How to Make the Pain Go Away with Ethan Benore, Ph.D

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Headaches may seem like an adult problem, but many kiddos know that crushing pain all too well. Nearly 1 in 4 adolescents report getting weekly headaches, and migraines are one of the most common diseases affecting children. It's enough to make a kid feel, well, not like a kid.

Today, we're going to look at the warning signs for childhood headaches and when you should be concerned. We're joined by pediatric psychologist Ethan Benore, who's focused much of his time at Cleveland Clinic on helping families find non-drug treatments for headaches. So, let's see what he has to say about how you can make your kids' headache pain disappear. Dr. Benore, thanks so much for taking some time to come in and chat.

Dr. Ethan Benore:

I'm happy to be here. Thank you.

John Horton:

So, today's topic, "Headaches in Children," is something that I know you've dedicated your career to resolving for families. What led you in that direction professionally?

Dr. Ethan Benore:

In my years of learning about psychology and how psychology can help children, I really got drawn to how psychology can help children who are struggling with medical conditions. And I have spent a lot of time working with individuals with pain, or headache in particular, and I just find joy in helping children learn a skill that eases suffering for them or gets them to a higher level of functioning. That moment where the child gets it and you know that they're going to be OK is, really. It's magical. It's fun. I love it.

John Horton:

I love the way you describe that, and you bring so much passion to this topic. So, thank you for that right off the bat. So, let's start, I guess, our talk on kid headaches by looking at how common it is, and I know I was stunned to see how many children deal with this sort of pain on a pretty regular basis.

Dr. Ethan Benore:

Sure. So, headaches are the No. 1 reason kids miss school. It's worldwide. It's one of the No. 1 symptoms that leads to disability. If you look at the numbers, it's about 4 out of 5 kids experience headaches.

John Horton:

That's amazing.

Dr. Ethan Benore:

Yeah. Yes, it is. Now, not all of them are suffering to the level of all the kids that come in to see me. When we take a look at migraines, which is one type of headache, now you're looking at maybe 5 percent of children or 15 percent of teenagers. It tends to increase during the teenage years.

And out of those individuals, some individuals develop what's called, about a quarter of those individuals develop what's called chronic headache, which is headache that's lasting more than three months, more than 15 days a month. And so those kids are seriously impacted by these symptoms.

John Horton:

Wow, 15 days a month is pretty, I mean, you can't function.

Dr. Ethan Benore:

Terrible.

John Horton:

Yeah, that is horrible. What about - you mentioned age a little bit. I mean, when can kids start getting headaches? I mean, are you seeing it when you're 2 or 3?

Dr. Ethan Benore:

You can see it when children are younger. However, sometimes, it's harder for children to communicate, and it's harder to pinpoint that. I have seen it in some toddlers. Typically, you'll pick up on it closer to age 5 when they're headed to school. And again, like I said, it's actually evenly split gender-wise, male and female, in childhood. And then, in adolescence, they haven't firmly set on why, but it tends to be about twice as common in girls than in boys in adolescence.

John Horton:

So, when it comes to headaches in children, what are some red flags that indicate the issue may be a larger problem?

Dr. Ethan Benore:

Yeah, this is a really good point to ask because headaches are so common that many people may say, "You know what, just give them some Tylenol®, put some ice on it, and we'll take a look at it tomorrow." There are some concerns that parents should take a look at.

So, if there is vomiting without nausea, if a child is waking up at night with a headache, or they have a headache when they wake up in the morning, a headache that presents in the back of the head can be a problem or headaches that are associated with neurological symptoms such as poor motor coordination. They're not moving their body in a very controlled way. They're having a fever with the headaches. They have significant lethargy. They look just kind of out of it like they've already taken some significant medicine. Or if your child had a head injury a day or a couple of days ago and now, they're presenting with a headache - all of those could be an indication of something more serious, as a neurological condition, and you really should get them looked at urgently. So, I would at least give your PCP a phone call, and then you might have to be followed up urgently to evaluate your child.

John Horton:

So, when I was researching this, one of the numbers that stuck out to me the most was how many different types of headaches there are, and I think I saw on one of the things, it was more than like 150 different types. I mean, you just think that a headache's, a headache, but it sounds like there's a lot of different things that can be going on up in your head.

Dr. Ethan Benore:

There are. There are. And yes, the doctors have come up with lots of different names for the different types of headaches. Now, the most common ones are going to be migraine or tension-type headache, and the cause of tension-type headache is going to be muscle tension, almost like a muscle cramp, but it's the muscles around the head. Migraine has to do with a process where the nerves are sending more pain signals. Again, these are nerves outside of your brain.

You actually don't have pain sensors in your brain. So, when we're talking about a headache, it's actually the nerves outside of the brain or around the head that are sending these signals. Those are the most common, but there are just a host of different things that could be going on in the brain or in the head that can lead to head pain. And that's where, if you're noticing any of these other symptoms, you really want to go see a neurologist and get a thorough examination.

John Horton:

Now, are there some kids that are just more prone to these serious types of headaches?

Dr. Ethan Benore:

Yeah, there's not good research on risk factors for these headaches in terms of how the child presents. There is, family history has been shown to be one factor, particularly with migraine. But unfortunately, I would say if your child is presenting with more of these serious symptoms, you just want to get it looked at. I can't identify a clear risk factor that would make one child more likely to develop a headache.

John Horton:

What about children just that are living in consistently stressful situations? And I take it that's got to be a big driving force also.

Dr. Ethan Benore:

So, you know when you - that's a good question - a lot of people have identified different triggers for headaches, and really the research has found, depending on which research you look at, multiple factors that can trigger headaches or lead to headaches to be more likely. That seems to be kind of individualized in terms of what sets headaches off.

So, some people will say it's chocolate, and some people will say it's nitrates, and some people will say it's caffeine. However, in the research, stress tends to be the most common factor. So upwards of 40 to 50 percent of causes of headache could be stress related. So, to your point, yes, a child who is in a stressful environment - if you are susceptible to developing headaches - stress is going to be a major cause of it.

John Horton:

OK. Well, now the big question: What can we do to help ease headache pain in children?

Dr. Ethan Benore:

Sure. So, most doctors will take a look at this as a three-pronged approach. The first would be lifestyle habits. The second would be preventative medication if needed, and the third would be an abortive plan or what to do when the headache rears its head. Let's start with healthy habits. These usually follow, a colleague had published this, so I have to give Dr. Bloom credit, the Smart Plan.

So, S-M-A-R-T. S stands for sleep. Make sure your child is getting appropriate sleep. There's clear evidence that lack of sleep or poor sleep, overall poor sleep quality can lead to headaches.

The M stands for meals and drinks. Make sure that your child isn't getting low blood sugar. They're eating regularly and eating appropriate nutrients. Also, dehydration tends to be a factor.

A stands for activities. With younger kids, it's usually just getting up and playing, but about 30 minutes of activity is important. I think, in today's world, that's especially important when we're having kids that are just spending a lot of time either sitting at their desks, sitting on their phones at their computer, or playing video games. You have to move your body.

The R stands for relaxation. Because in our society, we do have a lot of stress from various places, various sources, we actually have to learn how to recover from that. And so, relaxation is a skill that's been demonstrated in multiple studies over decades to help prevent headaches. And it's just a matter of learning the skill that works best for you.

And then the T just stands for trigger management, which is trying to do a little bit of research and figure out what seems to set your headaches off, and if it is this one event or if it is MSG or if it is smoke, then you work to try to avoid those triggers as best as possible.

John Horton:

Yeah. What stands out to me with the SMART method that you brought up was that that does not involve medication. Those are all things that you can do without opening a bottle. How often do those simple steps kind of resolve the problem?

Dr. Ethan Benore:

So, in many cases, they can. It hasn't typically, given where we're at with the research right now, it's always just put in there as recommendations. We are no longer just examining that without other studies, other interventions, but that alone can prevent headaches for individuals. So, it's important to start with that. I would say that that should be your first line of attack.

The second is preventative headaches or preventative medications, and there's conflicting research about the benefits of this. Some children respond, some children don't. Their doctors are continuing to try new medications. These are only for kids who are experiencing multiple headaches per month. And so, if you're experiencing a headache greater than once a week, you might want to talk to your doctor and consider preventative medication or what I do, which is teaching individuals relaxation and stress management as additional preventative medicine.

The third is the abortive medications, and that's really what you do when you have a headache.

Now, there's very good evidence to show that the nonsteroidal anti-inflammatory drugs, your Tylenol, Aleve®, Advil®, can be helpful, and you can work with your primary care doctor to identify the right dose and the right frequency. Most children will respond well if given the appropriate dosage as soon as possible. And I don't mean urgently in the next five minutes, but a lot of times, kids will get a headache, and they'll wait to see if it turns into a bad headache before they treat it. Sometimes, if you wait too long, those abortive medications don't really help you.

John Horton:

Are there worries about leaning on those medications a little too much? I mean, we're all a little easy. We go to that right away. Is it something that you should, if you do it every once in a while, it's OK, but if you're doing it regularly, you maybe should look for something else?

Dr. Ethan Benore:

No, it's a wonderful question. And this is actually something that we deal with a lot with patients. So, if you are taking over, if you are taking these abortive medicines too frequently, you actually can develop a different type of headache, one of the 150 headache types that you talk about, which is called medication overuse headache. And so, you actually can create headache symptoms by overusing these. And so, a good rule of thumb is that you're not going to be taking those medications, abortive medications, more than three times a week or more than 10 times a month.

John Horton:

Well, and that even seems like a lot. Which kind of leads me to the next question, which is, when is it time to talk to a healthcare professional about headaches in a child?

Dr. Ethan Benore:

Sure. So again, the leading recommendation is if you're having a headache more than once a week on average, you should get additional consultation. So that's the easiest way to describe it for individuals.

John Horton:

OK. And then, is this something you just talk about with your pediatrician, or do you need to go elsewhere?

Dr. Ethan Benore:

I would start with the pediatrician. It's often helpful because they know your history. Most likely, your pediatrician is, if your pediatrician is comfortable treating neurological conditions like headache, they may start you on a headache protocol. If not, or if there's any additional neurological symptoms that they want further evaluated, they may refer you to a neurologist. And then, that neurologist will generate an initial treatment plan for you, which should include healthy habits, potentially some preventative medications, or some people often benefit from like riboflavin, magnesium, and an abortive treatment plan.

And the abortive treatment plan doesn't have to be medication. So, I think it's important, as a family, if you have hesitations about some medications, that you talk with your doctor about that. There are other devices that have come on the market now to treat headaches. Sometimes, just lying down with a cool rag on your head, listening to some music can be helpful as you're waiting for the Advil or the Aleve to take effect. And so but working with a neurologist can be helpful to really clarify what that treatment plan is for you.

John Horton:

And doctor, you had mentioned that SMART method, and I think that was so fabulous. Let's go over it one more time, what the SMART stood for, just because I think that if someone's going to take something away.

Dr. Ethan Benore:

Oh, definitely.

John Horton:

Yeah.

Dr. Ethan Benore:

So, Sleep, Meals, Activity, Relaxation and Trigger management.

John Horton:

Some fabulous information there. And I think that is such a great starting point for parents if your child is dealing with a headache pretty regularly. Before we part ways today, is there anything else to add regarding kids and headaches and how it should be handled?

Dr. Ethan Benore:

Sure. There are probably two things that I would recommend or that I would want to say. The first is, as a pediatric psychologist, I don't do the medications. I'm not the medication guy, and so I am the person who, I work more on the behavioral methods, your lifestyle habits, as well as that relaxation training or stress management training because, as you brought up, stress is a huge factor. And so being able to attack the headache from those areas has often shown to be very, very beneficial. And so, if you have any hesitation about medications, there are very good established nonmedication interventions for these kids.

The second thing that I would say is if you're just now getting introduced to headache in your child, sometimes, headache is the first sign that something is going wrong, that your child is overwhelmed. And so, as a parent, you want to treat the headache. You want to treat the pain, but you might also want to take a little closer look at how your child is doing overall. Is your child stressed? Is your child being bullied? Is your child missing some sleep? Or is your child not eating right? And so maybe their nutrition is off. Does your child just need glasses? There are several factors that could trigger the beginning, a headache in the beginning. And so, as a parent, take the time to take a closer look at it. And again, if you have any questions, there's good resources online, but you also can talk to your primary care doctor.

John Horton:

And how important is it to really address these issues early? Because can these headache issues if they kind of start when you're young, can they follow you into adulthood and just kind of linger throughout your life?

Dr. Ethan Benore:

They definitely can. If you are prone to develop headaches and you're not doing the things you should be doing to manage your body or to condition your body in a way that you're less likely to experience headaches, you can continue to suffer more as you go through your childhood. And that can lead to secondary problems if you're missing school or struggling in school because of that. But then, it can follow you into adulthood and often does if it's not treated. And so, if you do identify headache as a problem in your child, wonderful to treat it now.

John Horton:

Well, the tips you gave us today should help everyone kind of deal with these issues a little earlier and hopefully find some relief. Dr. Benore, thank you so much for joining us today and sharing all this information.

Dr. Ethan Benore:

That's wonderful. Thanks for having me. I appreciate it.

John Horton:

If your child experiences frequent or serious headaches, talk to their pediatrician ASAP. Finding relief may be as simple as making a few lifestyle changes involving sleep, diet and stress. With any luck, it'll help your kid quickly get back to the business of being a kid. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.