Recurrent Headaches in Children and Adolescents
Information for Families
Introduction: Recurrent headaches defined as the occurrence of less than 15 days with headache/month, are common in children and adolescents (those under 20 years of age, referred to collectively as children).
Who gets it? About 50% of 7 year olds and almost 85% of 15 year olds report such headaches . Children as young as 2 years of age can complain of headaches. Boys and girls are equally affected. Girls may be more affected than boys in the late teens.
What are the causes of recurrent headache in this age group? In a recent Canadian study, more than a third (38%) had Migraine, about a quarter (18%) had Tension-type and about a third (32%) had mixed Migraine and Tension-type. Only 1% had tumors or vascular malformations. Thus, the overwhelming majority (88%) of children like adults, experience Migraine and Tension-type with tension-type being very common .Similar experiences have been reported from the United States and United Kingdom. It is of course important to exclude simple and common causes such as disturbances of vision and sinusitis. Sports related concussions can lead to recurrent headaches. Headaches may occur only with physical activity . The International Headache Society has published a current (2nd edition) of ?Classification of Headache Disorders.? There are between 150 and 200 types/sub-types of headache ! The history your child and you provide helps professionals decide on the headache type and cause. Hence, it is crucial to keep a written record of headache description and frequency.
Factors contributing to recurrent headache: Like most conditions, genetic predisposition is key. Over 70% will have a parent, brother/sister, uncle, aunt or grandparent with recurrent headache. Children with anxiety or depression may be more prone to recurrent headache and there may be a family history of such conditions.
Triggers for headache: Some of the factors that trigger headache are listed below. Please remember that triggers are unique for each child. Only your careful observations can identify triggers. There is no test that does. Allergy tests are of no value.
Stress Foods Others Others
School related Milk products Noise* Irregular sleep
Home related Eggs/cheese Sun* Fluorescent lights
Friends related Luncheon meats Weather Video games
Moves etc. Hot dogs Heat
Smells Chocolate Fatigue
Cigarette smoke* Oranges/tomatoes Missing breakfast
Menstruation Hunger
Perfumes Irregular meals
Other
* very common causes
Note: School factors include pressure of school work/assignments/exams, bullying, learning dysfunction. More than one factor can be responsible. We have had parents tells us that one kind of chocolate, cheese or pasta sauce can cause a headache and not others. Remember that cigarette smoke smell even second hand (from clothing) can be a cause of headache in your child. You have to be your own detective!
The Pattern: Headaches often occur in the afternoon or at the end of the school day, worsen at the start of school-term or during examinations/assignments and decrease during holidays. Some headaches occur only during physical activity. It is therefore important to keep a headache calendar so that you can identify the pattern of headache and recognize the triggers . It is important to record if headaches wake the child up from sleep or occur mostly in the morning after awakening. The person experiencing the headache should keep the chart. Remember that the person who has the headache is often in control of the causes.
What about serious causes for headache and tests to rule them out? Brain tumors are rarely a cause of headache particularly when the neurological examination is normal. In these circumstances it is not generally necessary to do a CT Scan or MRI Scan. However, your doctor will be aware of red flags that raise suspicion of such conditions and discuss the need for tests.
What about treatment for the headache?
(1) The 1st step is to keep a chart , identify possible triggers and deal with the triggers. Thus, if noise (example during recess, gym or on the school bus) is a trigger then using ear plugs will help out. If the sun is a trigger then tinted glasses can help. If many members of the household have recurrent headache think of an environmental factor (like cigarette smoke, leaking gas furnace etc). Many find non medication approaches like massage, cold or warm cloth on the head helpful. We cannot comment on chiropractic or other treatments.
(2) If stress is a trigger we must address it. Only you can identify stress in your family. We must not miss anxiety or depression.
(3) The headaches in 80% of children can be treated by dealing with triggers and using a simple analgesic like ibuprofen or acetaminophen (aspirin can be used in those over 12 years of age) in a dose appropriate for age and weight. The child should carry the appropriate medicine and take it as soon as the headache starts. Caution: using too much analgesics ( example 1 dose a day more than 15 days in a month) may cause ?analgesia drug related?? headache or increase frequency of headache.
(4) For those who have bad Migraine not helped by a simple analgesic and for those who experience severe nausea and vomiting early in a Migraine attack, there are specific medicines for Migraine (triptans) your doctor can discuss with you. Some of these come in the form of a nasal spray. The nasal form is better than oral if the child has severe nausea or if vomiting occurs early in the headache. Triptan tablets are rarely effective. These work only for Migraine, hence good description is important.
(5) For those who have frequent headaches (3-4/week), there are medicines that will need to be taken every day. Your doctor can discuss these with you. Once the medicine works, treatment is usually continued for a period of 3-6 months before gradually stopping it. These medicines include amitryptiline, cyproheptadine, pizotifen, propranolol, flunarizine, gabapentin, valproic acid, topiramate, indomethacin etc. Some drugs will only work for a particular headache type; hence, description of headache typesis important. For example, oxygen can be effective for cluster headache, indomethacin for benign (primary) exertional headache and paroxysmal hemicrania, propranolol for migraine. Amitryptiline, gabapentin, valproic acid and topiramate may be considered broad-spectrum anti-headache drugs ie., they are effective for more than one headache type.
Remember:
(i) that it is important for the child to be the key player in making decisions,
(ii) the chart you keep is crucial because the type of headache will help your doctor selected the medicine that will work the best, and
(iii) inform your doctor of any other medical condition (example asthma), your child may have because some medicines may not be suitable.
(iv) Depression and anxiety may co-exist with childhood headache.
(6) All medicines have possible side-effects. Hence, be familiar with the side-effects of the medicines prescribed. Always check with your pharmacist about inter-actions with other drugs, herbal remedies etc your child may be taking.
(7) All medicines have a chance of affecting the fetus. So young women should pre-plan pregnancies if medicines are being taken regularly and discuss this issue further with their doctor.
(8) Many of the medicines used in the treatment of headache in children and adolescents are ?off-label? ie they have not been formally approved for use in this age group.
Will children outgrow headache? The majority do. They can also ?control? their headaches by paying attention to their trigger factors.
A final Word! The child with headache, the child?s family and the child?s doctor are a ?team? and working together can help you-the child with headache. Regular follow-up with one doctor is important.
Please give us your feed-back on this information and help us to improve it further.
References
1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders (2nd edition). Cephalalgia 2004;24 (Supplement 1).
2. Lewis DW et al. Report of the Quality standards subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.Practice Parameter: evaluation of children and adolescents with recurrent headaches. Neurology 2002;59:490-498.
3. Pryse-Phillips WEM et al. Guidelines for the nonpharmacologic management of migraine in clinical practice. Can Med Assoc J 1998;159:47-54 (an excellent analyses on the subject).
4. Seshia SS. My head hurts: headaches in children. Can J.CME 1999;11:119-135.
5. Seshia SS. Mixed-migraine and tension-type: a common cause of recurrent headache in children. The Canadian Journal of Neurological Sciences (In Press). This paper emphasizes the frequency of mixed headache in children referred to a pediatric neurologist. It also lists the other causes for headache in a group of 320 Canadian children and adolescents.
Authors:
Dr S.S.Seshia, Dr. N.Lowry, and Mrs.Doris Newmeyer RN,
Division of Pediatric Neurology,
Dept. of Pediatrics,
University of Saskatchewan &
Royal University Hospital,
Saskatoon, Canada.
Dated June 2004.
Correspondence to : Dr.S.S.Seshia
http://www.medicine.usask.ca/pediatrics/services/pediatric-headache/recurrent-headaches-in-children-and-adolescents
Information for Families
Introduction: Recurrent headaches defined as the occurrence of less than 15 days with headache/month, are common in children and adolescents (those under 20 years of age, referred to collectively as children).
Who gets it? About 50% of 7 year olds and almost 85% of 15 year olds report such headaches . Children as young as 2 years of age can complain of headaches. Boys and girls are equally affected. Girls may be more affected than boys in the late teens.
What are the causes of recurrent headache in this age group? In a recent Canadian study, more than a third (38%) had Migraine, about a quarter (18%) had Tension-type and about a third (32%) had mixed Migraine and Tension-type. Only 1% had tumors or vascular malformations. Thus, the overwhelming majority (88%) of children like adults, experience Migraine and Tension-type with tension-type being very common .Similar experiences have been reported from the United States and United Kingdom. It is of course important to exclude simple and common causes such as disturbances of vision and sinusitis. Sports related concussions can lead to recurrent headaches. Headaches may occur only with physical activity . The International Headache Society has published a current (2nd edition) of ?Classification of Headache Disorders.? There are between 150 and 200 types/sub-types of headache ! The history your child and you provide helps professionals decide on the headache type and cause. Hence, it is crucial to keep a written record of headache description and frequency.
Factors contributing to recurrent headache: Like most conditions, genetic predisposition is key. Over 70% will have a parent, brother/sister, uncle, aunt or grandparent with recurrent headache. Children with anxiety or depression may be more prone to recurrent headache and there may be a family history of such conditions.
Triggers for headache: Some of the factors that trigger headache are listed below. Please remember that triggers are unique for each child. Only your careful observations can identify triggers. There is no test that does. Allergy tests are of no value.
Stress Foods Others Others
School related Milk products Noise* Irregular sleep
Home related Eggs/cheese Sun* Fluorescent lights
Friends related Luncheon meats Weather Video games
Moves etc. Hot dogs Heat
Smells Chocolate Fatigue
Cigarette smoke* Oranges/tomatoes Missing breakfast
Menstruation Hunger
Perfumes Irregular meals
Other
* very common causes
Note: School factors include pressure of school work/assignments/exams, bullying, learning dysfunction. More than one factor can be responsible. We have had parents tells us that one kind of chocolate, cheese or pasta sauce can cause a headache and not others. Remember that cigarette smoke smell even second hand (from clothing) can be a cause of headache in your child. You have to be your own detective!
The Pattern: Headaches often occur in the afternoon or at the end of the school day, worsen at the start of school-term or during examinations/assignments and decrease during holidays. Some headaches occur only during physical activity. It is therefore important to keep a headache calendar so that you can identify the pattern of headache and recognize the triggers . It is important to record if headaches wake the child up from sleep or occur mostly in the morning after awakening. The person experiencing the headache should keep the chart. Remember that the person who has the headache is often in control of the causes.
What about serious causes for headache and tests to rule them out? Brain tumors are rarely a cause of headache particularly when the neurological examination is normal. In these circumstances it is not generally necessary to do a CT Scan or MRI Scan. However, your doctor will be aware of red flags that raise suspicion of such conditions and discuss the need for tests.
What about treatment for the headache?
(1) The 1st step is to keep a chart , identify possible triggers and deal with the triggers. Thus, if noise (example during recess, gym or on the school bus) is a trigger then using ear plugs will help out. If the sun is a trigger then tinted glasses can help. If many members of the household have recurrent headache think of an environmental factor (like cigarette smoke, leaking gas furnace etc). Many find non medication approaches like massage, cold or warm cloth on the head helpful. We cannot comment on chiropractic or other treatments.
(2) If stress is a trigger we must address it. Only you can identify stress in your family. We must not miss anxiety or depression.
(3) The headaches in 80% of children can be treated by dealing with triggers and using a simple analgesic like ibuprofen or acetaminophen (aspirin can be used in those over 12 years of age) in a dose appropriate for age and weight. The child should carry the appropriate medicine and take it as soon as the headache starts. Caution: using too much analgesics ( example 1 dose a day more than 15 days in a month) may cause ?analgesia drug related?? headache or increase frequency of headache.
(4) For those who have bad Migraine not helped by a simple analgesic and for those who experience severe nausea and vomiting early in a Migraine attack, there are specific medicines for Migraine (triptans) your doctor can discuss with you. Some of these come in the form of a nasal spray. The nasal form is better than oral if the child has severe nausea or if vomiting occurs early in the headache. Triptan tablets are rarely effective. These work only for Migraine, hence good description is important.
(5) For those who have frequent headaches (3-4/week), there are medicines that will need to be taken every day. Your doctor can discuss these with you. Once the medicine works, treatment is usually continued for a period of 3-6 months before gradually stopping it. These medicines include amitryptiline, cyproheptadine, pizotifen, propranolol, flunarizine, gabapentin, valproic acid, topiramate, indomethacin etc. Some drugs will only work for a particular headache type; hence, description of headache typesis important. For example, oxygen can be effective for cluster headache, indomethacin for benign (primary) exertional headache and paroxysmal hemicrania, propranolol for migraine. Amitryptiline, gabapentin, valproic acid and topiramate may be considered broad-spectrum anti-headache drugs ie., they are effective for more than one headache type.
Remember:
(i) that it is important for the child to be the key player in making decisions,
(ii) the chart you keep is crucial because the type of headache will help your doctor selected the medicine that will work the best, and
(iii) inform your doctor of any other medical condition (example asthma), your child may have because some medicines may not be suitable.
(iv) Depression and anxiety may co-exist with childhood headache.
(6) All medicines have possible side-effects. Hence, be familiar with the side-effects of the medicines prescribed. Always check with your pharmacist about inter-actions with other drugs, herbal remedies etc your child may be taking.
(7) All medicines have a chance of affecting the fetus. So young women should pre-plan pregnancies if medicines are being taken regularly and discuss this issue further with their doctor.
(8) Many of the medicines used in the treatment of headache in children and adolescents are ?off-label? ie they have not been formally approved for use in this age group.
Will children outgrow headache? The majority do. They can also ?control? their headaches by paying attention to their trigger factors.
A final Word! The child with headache, the child?s family and the child?s doctor are a ?team? and working together can help you-the child with headache. Regular follow-up with one doctor is important.
Please give us your feed-back on this information and help us to improve it further.
References
1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders (2nd edition). Cephalalgia 2004;24 (Supplement 1).
2. Lewis DW et al. Report of the Quality standards subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.Practice Parameter: evaluation of children and adolescents with recurrent headaches. Neurology 2002;59:490-498.
3. Pryse-Phillips WEM et al. Guidelines for the nonpharmacologic management of migraine in clinical practice. Can Med Assoc J 1998;159:47-54 (an excellent analyses on the subject).
4. Seshia SS. My head hurts: headaches in children. Can J.CME 1999;11:119-135.
5. Seshia SS. Mixed-migraine and tension-type: a common cause of recurrent headache in children. The Canadian Journal of Neurological Sciences (In Press). This paper emphasizes the frequency of mixed headache in children referred to a pediatric neurologist. It also lists the other causes for headache in a group of 320 Canadian children and adolescents.
Authors:
Dr S.S.Seshia, Dr. N.Lowry, and Mrs.Doris Newmeyer RN,
Division of Pediatric Neurology,
Dept. of Pediatrics,
University of Saskatchewan &
Royal University Hospital,
Saskatoon, Canada.
Dated June 2004.
Correspondence to : Dr.S.S.Seshia
http://www.medicine.usask.ca/pediatrics/services/pediatric-headache/recurrent-headaches-in-children-and-adolescents
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