Headache
Headache: Children & Adolescents
By: Dawn A. Marcus, M.D.
Headache is a frequent, disabling complaint for adolescents. A survey of US high schools reported weekly headache in more than 20% of adolescents, with daily headache reported in 11% of girls and 3.5% of boys.1 Migraine is the most common type of chronic headache in school-aged children, with migraine affecting 11% of children between five and 15 years old, and tension-type headache in only 1%.2 The most common age for developing migraine is 12 years old.
Treating headache is important in children, since they lose an average of 7.8 days per school year, compared to 3.7 days lost per year for children without headaches.2 Once children have developed patterns of school disability, social withdrawal and failure to maintain family role, improvement in headache does not occur until disability is also addressed. The longer school absence is maintained, the more difficult it is for children to return to school because of failure to maintain academic work and fear of isolation from peers on return to school. The child will then desire to further isolate in the safe environment of the home, increasing social isolation, lack of appropriate academic involvement and headache activity.
The evaluation of pediatric headache requires a careful history, physical examination, and neurological examination.3 4 Headache descriptions are often different in children, compared to adults. For example, migraine in children is more likely to affect both sides of the head and last a short time compared with the typical adult migraine.5 6 Adolescents are less likely to describe their pain as throbbing or report sensitivity to noises and lights.7 Children should be encouraged to track their headaches in diaries and draw pictures of their headache symptoms to help the health care provider make an accurate diagnosis.
The headache evaluation should also look for current psychosocial stressors, such as school, family or relationship problems. One study identified significant personal stressors (family separation, moving, death) occurring within 12 months of headache onset in 73% of adolescents.8 Migraine occurs more often in children reporting unhappiness, fear of failure at school or fear of a teacher.9 Depressive symptoms are identified on clinical interview in 86% of teenagers with daily headache.10 In addition, being the victim of bullying is associated with frequent headache episodes in children between the ages of seven and a half and 10.11
In children presenting with acute headache, infectious etiologies, like viral illness and sinusitis, are common and should be considered.12 In children with acute or chronic headache, imaging studies are generally normal and are best reserved for children who have experienced traumatic headache, have a history of neurologic illness (such as hydrocephalus), or have an abnormal neurological examination. As in adult populations, when children experience a significant change in chronic headache pattern or fail to respond to standard therapy, they may also need additional work-up, such as an imaging study.
The same type of acute care and preventive medications used in adults are often effective in older children and adolescents. Treatments that have been proven to be effective in children and adolescents include:
When will my child's headaches go away so we can get back to a normal life?
Do not expect that headache will improve until your child returns to a more normal lifestyle. Neither the parents nor child can expect that the headache will go away before the child returns to his regular routine.
The lack of a regular routine and school attendance will actually aggravate your adolescent’s headache. Involvement in regular activities keeps the brain and nervous system busy. Lack of these activities allows the brain and nervous system to focus all of their attention on headache signals and pain. This actually increases the severity of the pain and worsens disability. Involvement in a regular routine distracts the brain. For example, walking may not seem very interesting intellectually, but it is very exciting for the brain and nervous system. Muscles and joints are moving at different rates, balance must be maintained, body temperature must be regulated, the eyes view the environment, and your mind may focus on a friend’s conversation. That takes a lot of energy and attention by the nervous system.
The first step in headache management is not getting rid of the pain, but getting rid of the misery of headache. This is done by resuming a regular routine. Function improves first, and pain improves later. As an adult, when you’re home sick from work you may feel miserable, both because of the health symptoms making you sick, but also because you miss the interaction with friends and co-workers, the lack of enjoyment of pleasurable activities you’re not doing, and the perception of yourself no longer as an interesting adult but as a sick person. The longer you’re home sick, the worse this misery becomes.
How do we get back to a more normal life?
Your child needs to resume a more regular routine. The number one job of the child is to attend school. School is important to social and emotional development in addition to intellectual development. Homebound education in children who are out of school because of headache is not a substitute for the classroom.
What if my child is already receiving homebound education?
Work with your child’s teachers and guidance counselor to get your child back into the classroom as soon as possible. For students who have already been receiving homebound education long-term, the initial focus needs to be on resuming a normal home routine before return to the classroom. Within a few weeks, return to school must follow, beginning with a gradual reentry if possible. Initially your adolescent should return to school to attend courses in which she has the most confidence, as well as lunch. If it is not possible to return to school part-time, then your child will need to return full-time.
Once back at school, your child should be allowed to leave the classroom to go to the nurse. Unless she is vomiting, however, she should be returned to the classroom after about 15 to 20 minutes. At the nurse’s office, the child may use some of those non-medication treatment techniques described below.
How do I know if stress is a factor for my child?
While stress alone doesn’t cause someone to start getting headaches, stress is the number one trigger for aggravating headaches both children and adults. There are many circumstances that increase stress for adolescents. These may include:
What's the role of non-drug techniques?
What is the parent's role?
Your job as parent is not to get rid of your adolescent’s headache pain. Don’t expect that you can make the pain go away. Your job is to assure that your child gets up, dressed and to school everyday. Your child should be attending school unless she is vomiting.
Your other important job is to help reinforce and encourage normal adolescent activities. He needs to identify himself by something other than the headache. Your adolescent, for example, should see herself as a 10th grader, violinist, athlete, good student, scout or avid shopper rather than as a headache patient. The headache should only be a small part of your adolescent’s identity.
Treating headache is important in children, since they lose an average of 7.8 days per school year, compared to 3.7 days lost per year for children without headaches.2 Once children have developed patterns of school disability, social withdrawal and failure to maintain family role, improvement in headache does not occur until disability is also addressed. The longer school absence is maintained, the more difficult it is for children to return to school because of failure to maintain academic work and fear of isolation from peers on return to school. The child will then desire to further isolate in the safe environment of the home, increasing social isolation, lack of appropriate academic involvement and headache activity.
The evaluation of pediatric headache requires a careful history, physical examination, and neurological examination.3 4 Headache descriptions are often different in children, compared to adults. For example, migraine in children is more likely to affect both sides of the head and last a short time compared with the typical adult migraine.5 6 Adolescents are less likely to describe their pain as throbbing or report sensitivity to noises and lights.7 Children should be encouraged to track their headaches in diaries and draw pictures of their headache symptoms to help the health care provider make an accurate diagnosis.
The headache evaluation should also look for current psychosocial stressors, such as school, family or relationship problems. One study identified significant personal stressors (family separation, moving, death) occurring within 12 months of headache onset in 73% of adolescents.8 Migraine occurs more often in children reporting unhappiness, fear of failure at school or fear of a teacher.9 Depressive symptoms are identified on clinical interview in 86% of teenagers with daily headache.10 In addition, being the victim of bullying is associated with frequent headache episodes in children between the ages of seven and a half and 10.11
In children presenting with acute headache, infectious etiologies, like viral illness and sinusitis, are common and should be considered.12 In children with acute or chronic headache, imaging studies are generally normal and are best reserved for children who have experienced traumatic headache, have a history of neurologic illness (such as hydrocephalus), or have an abnormal neurological examination. As in adult populations, when children experience a significant change in chronic headache pattern or fail to respond to standard therapy, they may also need additional work-up, such as an imaging study.
The same type of acute care and preventive medications used in adults are often effective in older children and adolescents. Treatments that have been proven to be effective in children and adolescents include:
- Non-drug therapies
- Relaxation
- Biofeedback
- Stress management
- Medications for acute headache management
- Ibuprofen
- Triptans (sumatriptan, zolmitriptan, rizatriptan)
- Medications for headache prevention
- Antidepressants (amitriptyline, trazadone)
- Antiepileptics (valproate, topiramate)
Practical Answers to Common Questions
When will my child's headaches go away so we can get back to a normal life?
Do not expect that headache will improve until your child returns to a more normal lifestyle. Neither the parents nor child can expect that the headache will go away before the child returns to his regular routine.
The lack of a regular routine and school attendance will actually aggravate your adolescent’s headache. Involvement in regular activities keeps the brain and nervous system busy. Lack of these activities allows the brain and nervous system to focus all of their attention on headache signals and pain. This actually increases the severity of the pain and worsens disability. Involvement in a regular routine distracts the brain. For example, walking may not seem very interesting intellectually, but it is very exciting for the brain and nervous system. Muscles and joints are moving at different rates, balance must be maintained, body temperature must be regulated, the eyes view the environment, and your mind may focus on a friend’s conversation. That takes a lot of energy and attention by the nervous system.
The first step in headache management is not getting rid of the pain, but getting rid of the misery of headache. This is done by resuming a regular routine. Function improves first, and pain improves later. As an adult, when you’re home sick from work you may feel miserable, both because of the health symptoms making you sick, but also because you miss the interaction with friends and co-workers, the lack of enjoyment of pleasurable activities you’re not doing, and the perception of yourself no longer as an interesting adult but as a sick person. The longer you’re home sick, the worse this misery becomes.
How do we get back to a more normal life?
Your child needs to resume a more regular routine. The number one job of the child is to attend school. School is important to social and emotional development in addition to intellectual development. Homebound education in children who are out of school because of headache is not a substitute for the classroom.
- Maintain a regular bedtime. Bedtime needs to be no later than 10 pm. If your child is unable to sleep, she can be allowed to listen to the radio or read a book. She should not be watching television or snacking after bedtime.
- Maintain a regular waking time. This time needs to allow adequate time for getting ready for school. Regular bed and rise times need to be maintained even for kids who are already out of school on homebound education.
- Maintain regular meal times. Your child must eat breakfast, lunch and dinner everyday.
- Maintain a regular homework time and location, not in front of the television or computer games.
- Maintain enjoyable leisure activities. These activities will preferably take your child out of the house and encourage socialization. Limit time playing computer games or surfing the Internet. Limit time spent watching television or movies. Encourage activities like walking, shopping or socializing.
What if my child is already receiving homebound education?
Work with your child’s teachers and guidance counselor to get your child back into the classroom as soon as possible. For students who have already been receiving homebound education long-term, the initial focus needs to be on resuming a normal home routine before return to the classroom. Within a few weeks, return to school must follow, beginning with a gradual reentry if possible. Initially your adolescent should return to school to attend courses in which she has the most confidence, as well as lunch. If it is not possible to return to school part-time, then your child will need to return full-time.
Once back at school, your child should be allowed to leave the classroom to go to the nurse. Unless she is vomiting, however, she should be returned to the classroom after about 15 to 20 minutes. At the nurse’s office, the child may use some of those non-medication treatment techniques described below.
How do I know if stress is a factor for my child?
While stress alone doesn’t cause someone to start getting headaches, stress is the number one trigger for aggravating headaches both children and adults. There are many circumstances that increase stress for adolescents. These may include:
- School course work
- Difficulty interacting with a peer group
- Excessive after-school commitments
- Depression
- Anxiety
- Fears of health conditions or illness
- Family strife
- Sexual issues
- Drug exposure or pressure
What's the role of non-drug techniques?
- Do not have your child follow diets that restrict foods. These diets are not likely to be helpful for most kids. These diets may also restrict kids both socially and nutritionally.
- Psychological intervention is usually very helpful. This may include pain management techniques, such as relaxation skills and biofeedback, coping skills and stress management. Problems with mood and anxiety should also be addressed. Parents should also be included in some of the therapy sessions.
- Relaxation skills are very effective for treating chronic headache. They work as well as many of the medication therapies. Although these techniques seem simple, learning them usually requires a few training sessions by a trained therapist, followed by regular home practice. Self-help books and tapes alone are often ineffective as trainers.
- Progressive muscle relaxation starts with sitting in a quiet room, in a comfortable chair, hands resting in your lap, with your legs not crossed. Close your eyes and practice tensing different muscle groups, one at a time. Tense your arms, then legs, then abdomen, shoulders, neck, jaw, eyes and forehead. Hold the tension for 10 to 15 seconds, then release. Focus on how you feel with your muscles tensed, then relaxed. You should practice this for 20 minutes at a time. Once you are familiar with this technique, you can monitor the tension in your muscles, comparing your sensations to those felt during this exercise. If tension in the muscles feels high, practice relaxation skills.
- Cue-controlled relaxation is also done sitting comfortably in a chair with hands in your lap and legs not crossed. Close your eyes and take a deep abdominal breath. Hold your breath for 10 seconds, then exhale. Repeat the word “relax” as you exhale. Place one hand over your abdomen to feel your belly move in and out with each breath. You should practice this for 15 minutes at a time. Once you have mastered this skill, you will be able to use deep breathing to become fully relaxed quickly throughout the day, such as when sitting on the bus or in class.
- Biofeedback is another relaxation skill that can be helpful for people who have difficulty with the techniques listed above. Biofeedback uses your body’s physical reactions, like muscle spasm or skin temperature, to show your success in using relaxation techniques. One type of biofeedback involves measuring hand temperature. Hand temperature should increase a few degrees when your muscles and nervous system relax. Simply warming your hands, without using relaxation techniques, will not be helpful.
- Begin a stretching exercise routine. Your adolescent should do 20 minutes of stretching each day. This can be done while listening to music, or even watching television. They should stretch only until they feel the normal sensation of stretching. They should not stretch until the muscle hurts. Each stretch should be held for five seconds. Then they should rest for five seconds, then repeat each stretch three times.
- Neck range of motion: Tilt your chin to your chest, then turn your chin to each shoulder, bend your each shoulder, and tuck in your chin like you’re making a double chin.
- Shoulder shrugs: Lift your shoulders straight up; then relax. Lift your shoulders up and forward; then relax. Lift your shoulders up and back; then relax.
- Suboccipital range of motion: Place a bath towel around the back of your neck and pull the ends down in front of you. Bend your chin to your chest, then look up at the ceiling, the tilt your ear to your shoulder on each side.
- Neck stretches: Tilt your ear to your shoulder on each side. Tilt your chin forward toward the opposite breast. Gently press with your hand at the end of the stretch to increase the stretch to the normal stretch point. Do not stretch until you feel pain.
- Neck isometrics: Place your hand on your forehead and press backward. Hold your head steady so that neither the head nor hand move. Repeat with your hand pressing on each side of your head and the back of your head.
- Head lift: Place folded hands behind your head at the base of the head where the neck and head join together. Pull your elbows forward and up to “lift” your head up from the neck.
- Turtle: Slide your chin forward away from your shoulders, like a turtle looking out of its shell. When your head is forward, turn it about one inch to either side, then one inch up.
- Whole body reconditioning should include whole body stretching exercises plus aerobic activities, like walking, swimming, or bicycling. These should be started at a low level, beginning at a slow pace and lasting a short time. They should be done at least three times per week, with the pace and distance or time at the activity gradually increased. For example, you may start walking ¼ mile a day, increasing by ¼ mile each week until one or two miles is walked at a time. Each day of participation in gym class also counts as a day of aerobic exercise.
- Flare techniques are used when a headache episode occurs to reduce pain. These can be done while putting ice packs or a heating pad on the neck. These techniques can be used at home or when your child goes to the nurse’s office with a headache.
- Oscillatory movements: These are pain-free, rhythmical, side-to-side movements of the head. The head should be moved only about 25% of its maximum range during these movements. First move your head from the center position away from the painful side. Oscillations should be done at a speed of one per second, for a total of 30 seconds. Repeat until no further pain relief is noted, then switch to moving your head in the direction of the painful side.
- Positional distraction: Place a stack of books one to two inches high on the floor and put a towel on top of them. Lay on the floor, resting your head on the books, with the edge of the books in the middle of your head. Your neck should be free. Relax your muscles so that your head moves up from your neck.
- Trigger point compression: Trigger points are muscles that cause an increase in your headache when you press on them. Look for trigger points in the muscles of your head, neck or shoulders. If you find trigger points, press on them with your fingers for 15 to 60 seconds. Then release the pressure and do your stretching exercises.
What is the parent's role?
Your job as parent is not to get rid of your adolescent’s headache pain. Don’t expect that you can make the pain go away. Your job is to assure that your child gets up, dressed and to school everyday. Your child should be attending school unless she is vomiting.
Your other important job is to help reinforce and encourage normal adolescent activities. He needs to identify himself by something other than the headache. Your adolescent, for example, should see herself as a 10th grader, violinist, athlete, good student, scout or avid shopper rather than as a headache patient. The headache should only be a small part of your adolescent’s identity.
References
- Rhee H. Prevalence and predictors of headaches in US adolescents. Headache 2000;40:528-538
- Abu-Arefeh I, Russell G. Prevalence of headache and migraine in schoolchildren. BMJ 1994;309:765-769.
- Rothner AD. Headaches in children and adolescents. Child Adolesc Psychiatr Clin N Am 1999; 8:727-745.
- Annequin D, Tourniaire B, Massiou H. Migraine and headache in childhood and adolescence. Pediatr Clin N Am 2000; 47:617-631.
- Winner P, Putnam G, Saiers J, O’Quinn S, Asgharnejad M. Demographic and migraine characteristics of adolescent patients: the Glaxo Wellcome adolescent clinical trials database. Headache 2000;40:438.
- Raieli V, Raimondo D, Cammalleri R, Camarda R. Migraine headaches in adolescents: a student population-based study in Monreale. Cephalalgia 1995;15:5-12.
- Wober-Bingol C, Wober C, Karwautz A, et al. Diagnosis of headache in childhood and adolescence: a study of 437 patients. Cephalalgia 1995;15:13-21.
- Kaiser RS, Primavera JP. Failure to mourn as a possible contributory factor to headache onset in adolescence. Headache 1993;33:69-72.
- Anttila P, Metsahonkala L, Helenius H, Sillanpaa M. Predisposing and provoking factors in childhood headache. Headache 2000;40:351-356.
- Kaiser R. Depression in adolescent headache patients. Headache 1992;32:340-344.
- Williams K, Chambers M, Logan S, Robinson D. Association of common health symptoms with bullying in primary school children. BMJ 1996;313:17-19.
- Burton LJ, Quinn B, Pratt-Cheney JL, Pourani M. Headache etiology in a pediatric emergency department. Pediatr Emerg Care 1997;13:1-4.
- Kan L, Nagelberg J, Maytal J. Headaches in a pediatric emergency department: etiology, imaging, and treatment. Headache 2000;40:25-29.