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 percent of boys and 74 percent 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 an underlying disease.

Many headaches in children and adolescents are the result of stress and muscle tension. Headaches are also common symptoms of sinus 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 percent of all children and adolescents have had migraines and 15 to 20 percent 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 in 1988 and revised in 2003. It includes more than 150 diagnostic headache categories. In general, headaches are classified as:

• Migraines -- episodic severe headaches with nausea and vomiting
• Tension, chronic daily headache or chronic non-progressive headache -- muscle contraction headaches that occur daily or periodically
• 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.

Our classification of headaches at the Cleveland Clinic includes:

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) or hemorrhage (bleeding within the brain). Children and adolescents with these problems usually have neurological symptoms (including stiff neck, seizures) and have other signs of illness in addition to the headaches.

Acute recurrent headaches or migraines -- 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 on one or both sides of the head. Common symptoms of migraine in children and adolescents include pallor, nausea and vomiting. The child may also be very sensitive to light, noise or smells and want to sleep.

Chronic nonprogressive headaches or tension headaches -- daily headaches or frequent 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.

Mixed headache syndrome -- combination of migraine and chronic nonprogressive (tension) headaches.

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, balance 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:

• 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
• 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 drug 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 have been taken in the past and what medications are currently being taken. 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.

Skull X-rays are not helpful. An EEG (electroencephalogram) 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 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
Education includes learning about your headache type and recording what triggers the headaches, such as lack of sleep, a poor diet, your environment or stress. Your doctor will 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 or exercising strenuously

Other ways to relax or reduce stress include:

• Deep breathing exercises
• Progressive muscle relaxation
• Mental imagery relaxation
• Relaxation to music
• Biofeedback
• Counseling (can help patients recognize and relieve stress)

Biofeedback
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
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 triptans -- sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax); ergotamine tartrate and caffeine (Cafergot); dihydroergotamine mesylate (DHE-45, Migranal); and a combination medication (Midrin). 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: nonsteroidal anti-inflammatory (NSAID) drugs, antidepressants, antihistamines, beta blockers, calcium channel blockers, or anticonvulsants. Most of these medications require a prescription and take several weeks to work.

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.

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By Michael G. McKee, PhD, Section of Health Psychology, Department of Psychiatry and Psychology