Headache: A-to-Z Guide from Diagnosis to Treatment to Prevention

Headaches are quite common in children. An older child will say, “My head hurts…”A toddler, though, may just act cranky, rub his head, or try to find a darkened room. In a young child, vomiting may be the only clue. Most headaches are minor, but because headaches can sometimes be clues to serious problems, they should never be ignored.

What is a headache?

Often children have headaches accompanying specific minor illnesses, such as strep throat or influenza. These headaches are sporadic, and are usually not the primary symptom themselves.

Recurrent headaches are a different phenomenon.

The most important causes of recurrent headaches in children are migraines, organic headaches, and stress or tension headaches.

Migraines primarily involve the blood vessels of the head. They are caused by an inherited extra-sensitivity of certain blood vessels to the nerve and chemical signals that normally cause these vessels to dilate or constrict (especially to serotonin, norepinephrine, and substance P). When these over-exuberant blood vessels expand and contract, the resulting changes produce pain.

Tension headaches usually arise from the muscles of the head and scalp.

Organic headaches are far less common, but far more serious. They often arise from an increase in pressure in the skull, and can be caused by such underlying problems as brain tumors, meningitis, encephalitis, lead poisoning, or hydrocephalus.

Other sources of headache, such as vision problems, sinus infections, and dental problems, are less of an issue for most children.

Who gets a headache?

Anyone can get a headache.

Migraines are much more common than most people suspect. They are the most important and frequent type of headache in children, affecting more than one in twelve kids — yet only 20 percent of children with migraines are ever properly diagnosed and treated. Before puberty, migraines are more common in boys than in girls. The reverse is true afterwards. The great majority of children with migraines also have a family history of migraines.

Organic headaches are uncommon, and can occur at any age.

Stress or tension headaches are uncommon in young children, but become increasingly common as children go through puberty.

What are the symptoms of a headache?

Childhood Migraines
Migraines are defined as recurrent headaches (in which the child is well between episodes) accompanied by at least 3 of the following symptoms:

• Abdominal pain
• Nausea or vomiting
• Throbbing or pounding headache
• Specific location of pain
• Associated “aura”
• Relief with sleep
• Family history of migraines

Some less common types of migraines (such as cyclic vomiting) may have no headache at all.

Organic Headaches

• Headaches that awaken children, or early morning headaches, are probably not migraines. They might be signs of increased pressure in the skull.
• Early morning vomiting
• Generalized location of pain
• Other associated neurological symptoms such as visual loss, numbness, weakness, difficulty walking, or changes in behavior.
• Worse with coughing, sneezing, or stooling

Tension Headaches

• Most often during the school day or after school
• No nausea or vomiting
• Head aches or hurts, but does not throb or pound
• Often pain in the front of the head
• Often better on weekends

Is it contagious?

No. The headache itself is not contagious, although the underlying cause may be.

How long does a headache last?

The length of the headache varies tremendously, depending on the underlying cause.

How is a headache diagnosed?

Children with recurrent headaches should be evaluated by a physician to determine the cause. Keeping track of when headaches occur, where the pain is felt, and what helps the pain improve can help your doctor determine the cause for the headaches. The type of headache is often apparent from the history and physical exam.

If the headaches are unusual or not responsive to standard treatments, a referral to a neurologist may be needed.

Some children with headaches should have an MRI or CT scan of the head. Reasons for this might include headaches that awaken a child from sleep, early morning headaches, early morning vomiting, seizures, vision loss, or an abnormal neurologic exam.

How is a headache treated?

Treatment of organic headaches is aimed at the underlying disorder. Treatment of stress headaches might include mild pain medicines and a variety of relaxation techniques.

Exciting new drugs have been developed for adults with migraines. While some of these may be used in children, kids are much more responsive than adults to available, gentle medicines.

Ibuprofen (Motrin or Advil) is more than twice as effective as acetaminophen (Tylenol) at stopping a migraine, but acetaminophen starts working twice as fast. I recommend giving a child a dose of both ibuprofen and acetaminophen when the headache starts, and then having him rest in a quiet, darkened room. Most kids get quite sleepy with migraines, and want to lie down. They usually awake refreshed and headache-free.

If vomiting is a major symptom, giving a prescription anti-vomiting medicine at the beginning of the headache can be the most important part of treatment.

These simple measures will give effective relief to most kids. Stronger prescription medicines (such as ergotamine or sumatriptan) might be used if pain continues to be a problem.

How can a headache be prevented?

Helping kids with migraines begins with carefully observing the circumstances involved when the headaches begin. Identifying and avoiding their migraine triggers can make a big difference in kids’ lives.

A number of foods have been shown to be triggers for some individuals. The most common of these are nuts, chocolate, cola drinks, hot dogs and luncheon meats (probably the nitrates and nitrites), pepperoni and sausage (thought, perhaps, to be the spices), kippers (not a major food for most kids!), and MSG (found in Chinese food and in restaurant salads — another non-issue for most kids). Both alcohol and birth control pills are associated with migraines, but there are better reasons than headaches to avoid these in young children.

Bright flashing lights can also trigger migraines. This happened on a large scale to many children watching a cartoon in Japan (this cartoon also triggered seizures in many children, which of course captured more attention than the migraines).

Children who get migraines (and tension headaches) are more likely to get them when they are over-tired or have gone too long without eating. In addition to fatigue and hunger, other known triggers are sun exposure, excessive physical exertion, motion sickness, loud noises, head bumps, stress, and anxiety.

Even if the triggers can’t be avoided, children who learn what their triggers are often experience a great reduction in the number of headaches. Perhaps their brains are more ready to deal with the surges of serotonin or other substances.

If the migraines are very frequent, or are interfering with school, then a continuous, daily medication might be prescribed to prevent the migraines. These are all strong medicines with significant side effects, so I would only use them if the headaches are seriously impacting your child’s life.

I prefer teaching children either self-hypnosis or biofeedback to control their headaches. Most kids in second grade or above can master these techniques. They have been shown to be even more effective than most medicines at preventing migraines.

Many of the behavioral techniques that help prevent migraines will also prevent tension and stress headaches.

Related concepts:

Migraine, childhood migraine, stress headache, tension headache