Is Your Child’s Headache Cause for Concern?

When your child complains of a headache, it can be anything from a plea to stay home from school in hopes of avoiding a test, to a sign of something more serious. But how can you tell the difference? And when is it time to see the pediatrician? Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s, offers advice on what parents can do to keep headaches at bay, the importance of identifying a pattern in your child’s headaches, options for treatment, and what types of headache warrant a trip to the emergency department.

sharief-taraman-choc-childrens-pediatric-neurologist-offers-advice-childs-headaches
Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s, offers advice for parents concerned about their child’s headaches.

First, it’s important to be able to identify what type of headache your child may be suffering from.

What type of headache does my child have?

Migraine symptoms in kids

At least 5 attacks that meet the following criteria:

  • Headache lasting 1 – 72 hours
  • Headache has at least two of the following features:
    • Pain on both sides or only one side of the head
    • Pain is pulsating
    • Moderate to severe intensity
    • Aggravated by routine physical activities
  • At least one of the following:
    • Nausea and/or vomiting
    • Sensitivity to light or noise

If your child has more than 15 headache days per month over a three-month period, and at least half of those are migraines, they may be suffering from chronic migraines.

It’s a common misconception to assume that only adults suffer from migraines, which isn’t true, says Dr. Taraman. If your child has migraines, they are not alone. About 1 out of every 20 kids, or about 8 million children in the United States, gets migraines. Before age 10, an equal number of boys and girls get migraines. But after age 12, during and after puberty, migraines affect girls three times more often than boys.

Tension headache symptoms in kids

  • Headache lasting from 30 minutes to seven days
  • Headache has at least two of the following characteristics:
    • Pain in two locations
    • Pressing or tightening feeling (not a pulsing pain)
    • Mild to moderate intensity
    • Not aggravated by routine physical activity such as walking or climbing stairs
  • No nausea or vomiting – many children experience a loss of appetite
  • Either sensitivity to light or sensitivity to sound
  • Tension headaches occur most often in children ages 9-12

Cluster headache symptoms in kids

  • At least five headaches that meet the following criteria:
    • Severe pain in one location: within the eye, above the eyebrow, or on the forehead, that lasts from 15 minutes to three hours when left untreated
  • Headache is accompanied by at least one of the following symptoms on the same side of the body as their pain:
    • Conjunctival injection and/or lacrimation
    • Nasal congestion and/or excess mucus in the nose
    • Eyelid swelling
    • Forehead and facial swelling
    • Droopy eyelid and/or small pupil
    • A restlessness or agitation
  • Cluster headaches usually start in children at around 10 years old

Post traumatic headache symptoms in kids

  • Acute post traumatic headache: lasts less than three months and caused by a traumatic injury to the head
  • Persistent post traumatic headache: lasts more than three months and caused by a traumatic injury to the head
  • Both acute and persistent headaches develop within one week of: the injury to the head, regaining of consciousness following injury to the head, or discontinuing medicine that impairs the ability to sense a headache following a head injury
  • Extended recovery risk factors:
    • Prolonged loss of consciousness or amnesia
    • Females
    • Initial symptom severity
    • Premorbid history of ADHD, mood disorders, and migraines

Sleep apnea headache symptoms in kids

  • Typically occurs in the morning
  • Pain is present on both sides of the head
  • Lasts more than four hours
  • Not accompanied by nausea, nor sensitivity to light or sound

Medication overuse headache symptoms in kids

  • Headaches on 15 or more days per month
  • Takes over-the-counter medication for headaches more than three times per week over a three-month period
  • Headache has developed or gotten worse during medication overuse
  • Pattern of headaches resolves or improves within two months after discontinuing the overused medication

What to do when your child has a headache

A variety of non-medical interventions can be helpful for children who are suffering from headaches. These non-medical interventions for headaches include: ice packs; warm baths; taking a nap in a cool, dark room; neck and back massage; and taking a walk.

Parents shouldn’t be tempted to immediately turn to medication such as ibuprofen or naproxen, says Taraman.  Over-the-counter pain medications (such as Tylenol or Motrin) should be limited to no more than three days per week with no more than two doses per day, in order to avoid medication overuse headaches. Follow the dosing instructions on the label and ask your child’s pediatrician or pharmacist any questions before beginning a treatment regimen. Follow dosage instructions given by your physician or pharmacist, or download a guide to ibuprofen and naproxen.

dosing-instructions-ibuprofen-naproxen

How to avoid headaches

There are a number of things parents can do to prevent headaches, says Dr. Taraman. These include:

How to talk to your pediatrician about your child’s headaches:

Keep a journal of your child’s headaches so you can identify a pattern, and show your child’s primary care physician. If you don’t have a primary care provider, find one near you. In your headache journal, keep track of:

  • Headache start date and time
  • What happened just before the headache?
  • How much did your head hurt, on a 0-10 pain scale?
  • Where did your head hurt?
  • What did you feel just before and during the headache?
  • What did you do to make yourself feel better?
  • Did you feel better, on a 0-10 pain scale?
  • Headache end date and time

Your child’s pediatrician may adjust your child’s diet, headache hygiene routine, or their NSAID regime. In some cases, your primary care provider may refer you to a pediatric neurologist, who have specialized training in the nervous system (brain, spinal cord, muscles and nerves), who work in tandem with imaging and other specialists and pediatricians as necessary.

Patients should immediately be taken to the emergency department for some headaches including:

  • Thunderclap headache: severe, sudden onset of pain that occurs anywhere in the head, and grabs your attention like a clap of thunder. Pain usually peaks within 60 seconds to a few minutes.
  • Any headache that comes with weakness or numbness on one side of the body, or changes in consciousness or awareness.
  • Blurred, double or loss of vision that persists after the headache resolves.

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What’s Causing your Child’s Headaches?

By Dr. Nancy Shan, pediatric resident at CHOC Children’s

Headache complaints can be bewildering and frightening to many parents. Most are caused by a benign (simple) problem or primary headache disorder. Very rarely are headaches a sign of a serious underlying condition. Headaches are more common in boys than girls under 7 years of age, but the gender prevalence changes around puberty.

Headaches are often referred to as either primary or secondary. Primary headache disorders include migraines, tension headaches and chronic headaches. Tension headaches are the most commonly diagnosed type in children. Chronic daily headaches are defined as at least 15 days of headache in one month.

Secondary headaches are those caused by an underlying medical issue. Of children who are seen in the emergency department for headaches, the most common culprit is an acute febrile illness, like the common cold, the flu, or sinusitis. Typically, these headaches will go away when the illness resolves. Rare causes of secondary headaches occur when there is elevated pressure in the brain, which can be due to increased cerebrospinal fluid (CSF), a space occupying process (infections and brain tumors), pseudotumor cerebri, and low intracranial pressure (from leakage of CSF). Medication overuse headaches are due to excess use of medication to manage headaches. It is recommended that patients use medications such as ibuprofen or acetaminophen no more than three times per week to help prevent overuse headaches.

Children with uncorrected vision can experience headaches due to prolonged eye strain. After age 6, children with vision screens worse than 20/30 should be referred to an optometrist, who can conduct an evaluation to see if the child requires glasses. If it is recommended that your child wears glasses, make sure they do so regularly!

Other possible causes of recurrent headaches are listed below, and can be remembered with the mnemonic “SMART,” which was created by pediatric neurologist Dr. Heidi Blume:

  • S is for sleep. Not enough sleep and too much sleep (or any disruption to a regular sleep schedule) can cause headaches. Children in school should get between 8-10 hours of sleep every night
  • M is for meals and eating at least three full meals a day. As children get older and school starts earlier, many begin to skip breakfast. If there is no time for a sit-down breakfast, having a granola bar, a cup of yogurt or even some fruit on the go is better than nothing. Hydration is also important. A simple way to check hydration is to look at urine color: it should be clear.
  • A is for activity, and believe it or not, too little or too much activity can lead to headaches, although typically it is the former that ails children. Children should be getting at least one hour of physical activity (outside of school regulated gym class) every day.
  • R is for relaxation. High schoolers begin to experience an exponential amount of stress from schoolwork, peer pressure, and post-high school planning.
  • T is for avoiding any known triggers, which can be specific foods, smells or environments.

Typically, the cause of headaches will not be found at the initial doctor’s visit. After a careful history and a thorough physical exam to exclude any causes of secondary headaches, children and families are encouraged to keep a headache diary. Entries should be as specific and descriptive as possible regarding each headache episode.  The diary should then be brought to follow-up appointments, usually within 2-3 weeks of the initial examination. Between visits, patients are encouraged to use the “SMART” mnemonic to optimize their daily routines.

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Migranes: Not Just an Adult Ailment

Think only grown-ups get migraines? Think again. This painful neurological condition is also common among children.

In fact, one in 20 children – or about 8 million children nationwide – experience migraine headaches. While migraines may be very painful, the good news is that kids can take steps to help prevent the ache.

Dr. Sharief Taraman, a CHOC Children’s neurologist, explains a migraine’s symptoms and causes, treatment methods, and what patients and their families can do to minimize migraines.

Head pain, other symptoms
Migraines are a specific type of headache, Dr. Taraman says. Sufferers endure throbbing, pulsating or pounding pain, either on one side of the head or both. Migraines may also impose a host of other symptom:

• Abdominal discomfort
• Nausea and/or vomiting
• Light sensitivity
• Noise sensitivity
• Dizziness or lightheadedness

But even with these symptoms, it might not always be clear that a child is suffering from a migraine because symptoms are often disconnected in children, Dr. Taraman says. For example, a child might have a stomachache but no headache, or perhaps light sensitivity but no nausea.

Children also might have difficulty expressing what exactly is bothering them, he explains. Parents should work with children to help them describe their symptoms and keep a close eye on behaviors. For example, a child might seek out a dark, quiet room but not specifically complain that lights or noises are bothering them.

The trigger factor

Migraines start when blood vessels in the brain constrict. This limits the amount of blood and oxygen flowing into the brain, which causes other blood vessels to expand. These dilating blood vessels become inflamed and result in a pounding headache or the other associated symptoms.

Certain environmental factors can often trigger migraines and the causes can differ among sufferers.

Triggers vary, but they can be linked to diet, hormones or even too much screen time, Dr. Taraman says. Common edible migraine culprits include chocolate, cheeses, and foods treated with nitrates, like lunch meat and pepperoni.

Dr. Taraman recommends that children keep a diary to help uncover migraine triggers. Document when migraines occur and what the child ate, did or experienced in the days prior. Be sure to build in some extra time: Often a certain food or behavior might lead to a migraine the next day.

Migraine diagnosis, treatment
There’s no blood test that can diagnose migraines and imaging is seldom needed, Dr. Taraman says. Instead, physicians rely on a physical examination and family history.

“Family history is huge,” he says. “Migraines run in families.”

Once a child knows he or she is experiencing migraines, over-the-counter pain relievers can help dull the ache. However, Dr. Taraman reminds parents to follow directions and avoid overuse.

Overusing over-the-counter pain relievers, more than twice a month, can result in “rebound headaches,” or head pain that develops even more intensely after medication wears off.

Finding a dark, quiet place to rest can help a child battle a migraine, as can warm or cold compresses, Dr. Taraman says. However, each person responds to temperature differently, so families can experiment with warmth or cold to see what method works best for their child, he advises.

Parents of chronic migraine sufferers should alert their child’s teacher and school nurse to the condition. The school, parents and child can work together to ensure that the student can leave class if necessary and find a quiet place to rest until the pain subsides.

Finally, if a headache is ever accompanied by weakness or numbness in one side of the body or slurred speech, parents should take the child to the emergency department immediately, Dr. Taraman cautions. This could be a symptom of stroke, which do occur in children.

‘Headache hygiene’ aids prevention
Because environmental factors can trigger migraines, kids can take measures to help keep migraines at bay, Dr. Taraman says. After keeping a diary and determining trigger foods or behaviors, avoiding these red flags can help tremendously.

In addition, general healthy habits can also stave off migraines. These steps are part of good “headache hygiene.”

• Get enough sleep
• Eat a balanced diet
• Stay properly hydrated
• Cope with stress
• Get plenty of exercise

Learn more about CHOC Children’s Neuroscience Institute.

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Kids and Headaches

girl_headacheWHAT IS A HEADACHE?

A headache is pain or discomfort in the head or face area. It can be acute (sudden) or chronic (recurrent). “For a child with an acute headache, you want to make sure there are no other problems that need to be addressed, such as an infection,” says Fernandez. If a child has chronic headaches, but their neurological (nervous system) exams are normal, migraines may be the problem.

MORE ABOUT MIGRAINES

Although there are no blood tests to determine if a child has a migraine, family history usually helps physicians pinpoint the diagnosis. Migraines can be brought on by food triggers, such as chocolate, cheeses and foods with preservatives such as nitrates. Nitrates can be found in favorite childhood foods including hot dogs and bologna, says Fernandez. Environmental elements including glare and sun exposure can also set them in motion. So how can you tell if your child has a migraine? Pay attention to these common symptoms:

  • Abdominal discomfort
  • Nausea and/or vomiting
  • Pain on one or both sides of the head
  • Facial pallor (paleness) during headache
  • Relief of headache pain with sleep

PAIN RELIEVERS

Responding quickly is key to treating headaches and migraines. Over-the-counter pain relievers such as ibuprofen should be taken right away. “If you wait too long, nothing is going to help,” says Dr. Fernandez. Letting your child rest in a dark room or applying cold compresses are other ways parents can help ease the pain.

How can children practice proper headache hygiene?

Establishing good habits can help keep headaches at bay. These headache hygiene measures can help:

  • Regulate your child’s sleep
  • Find ways to help them cope with stress
  • Avoid triggers
  • Eat nutritious meals consistently
  • Drink at least 8 glasses of fluid per day for adequate fluid intake
  • Exercise at least 5 times per week for 30 minutes or more. This can help with stress and depression as well.

FAST FACTS

  • When tension headaches occur most often: 9-12 Years Old
  • When migraines may start: 5-8 Years Old
  • When cluster headaches usually start: 10 Years Old

View the full feature on Kids and Headaches

Dr. Amanda N. Fernandez
Dr. Amanda N. Fernandez
CHOC Neuroscience Institute

PHYSICIAN FOCUS: DR. AMANDA N. FERNANDEZ

Dr. Fernandez completed her pediatric residency at Kings County Hospital in Brooklyn, NY and her fellowship in Pediatric Neurology at the University of Miami/Jackson Memorial Medical Center. She is a member of the American Academy of Neurology, American Epilepsy Society and the Child Neurology Society.

Dr. Fernandez’s philosophy of care: “My philosophy is family-centered; looking at the child’s whole picture of health. It’s not just treating the pain or headache, but understanding the other psycho-social reasons for their pain.”

EDUCATION:
University of the East, Ramon Magsaysay Memorial Medical Center, Philippines

BOARD CERTIFICATIONS:
Pediatrics and Child Neurology

More about Dr. Fernandez | More about the CHOC Neuroscience Institute

This article was featured in the Orange County Register on September 9, 2013 and was written by Shaleek Wilson.