Patient education: Headache in children (Beyond the Basics)
- Daniel J Bonthius, MD, PhD
Daniel J Bonthius, MD, PhD
- Professor of Pediatrics and Neurology
- University of Iowa Carver College of Medicine
- Andrew G Lee, MD
Andrew G Lee, MD
- Professor of Ophthalmology, Neurology, and Neurological Surgery
- Weill Cornell College of Medicine
- Andrew D Hershey, MD, PhD, FAHS
Andrew D Hershey, MD, PhD, FAHS
- Endowed Chair and Director of Neurology
- Cincinnati Children's Hospital Medical Center
- Professor of Pediatrics and Neurology
- University of Cincinnati College of Medicine
- Section Editors
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Marc C Patterson, MD, FRACP
Marc C Patterson, MD, FRACP
- Section Editor — Pediatric Neurology
- Professor of Neurology, Pediatrics, and Medical Genetics
- Chair, Division of Child and Adolescent Neurology
- Mayo Clinic College of Medicine
- Jerry W Swanson, MD, MHPE
Jerry W Swanson, MD, MHPE
- Section Editor — Headache
- Professor of Neurology
- Mayo Clinic College of Medicine
Headaches are common in children, occurring in up to 75 percent of school-age children. The likelihood of headaches is greater in adolescents than in younger children. There are many possible causes of headaches, from common and non-harmful to more serious but rare conditions.
This topic reviews the causes, evaluation, and treatment of headaches in children. A separate topic discusses headaches in adults. (See "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)" and "Patient education: Headache treatment in adults (Beyond the Basics)".)
There are numerous possible causes of headaches in children. The most common causes include the following:
●Viral or upper respiratory infections (including ear infections, the common cold, allergies, sinus infections, strep throat)
●Stress-related or stress-worsened headaches (eg, family or school problems)
●Minor head injury
Only a small minority of children with headaches have a serious cause, such as a brain tumor or life-threatening infection.
TYPES OF HEADACHES
The symptoms of a headache in a child depend upon the child's age and the type of headache. The most common types of headaches in childhood are illness or injury-related, tension-type, migraine, and cluster.
Illness or injury-related headaches — Viral or upper respiratory infections are a common cause of headaches in children. The headache may last for several days during the course of an illness.
Bacterial meningitis, a serious and life-threatening infection, can also cause a headache, usually accompanied by other symptoms. Other symptoms may include fever, sensitivity to light, neck stiffness, nausea, vomiting, confusion, lethargy, and/or irritability. (See "Patient education: Meningitis in children (Beyond the Basics)".)
Head injuries, which can occur at home, school, or while playing sports, are a common cause of headaches. Children who have a head injury and who also have nausea, vomiting, loss of consciousness, or other worrisome signs or symptoms should be evaluated by a healthcare provider. (See 'When to seek help' below and "Patient education: Head injury in children and adolescents (Beyond the Basics)".)
Tension-type headaches (TTH) — Tension-type headaches (TTH) cause a pressing tightness around both sides of the head or neck. The pain is usually mild to moderate, does not throb, and it may last from 30 minutes to several days. Some children with TTH have nausea or are sensitive to light or noise or feel lightheaded or tired. TTH does not usually cause vomiting and is not made worse by normal daily activities.
Migraine headaches — The symptoms of migraine vary with age. Migraines in children may have different symptoms than in adults.
●In toddlers, a caregiver may notice that the child is pale and/or less active than usual. An older child may vomit, cry, rock in place, or hide. Occasionally, toddlers with migraine become temporarily unsteady and off-balance, and act as though they are afraid to walk.
●In young children, the headache often begins in the late afternoon. The pain is usually pounding or throbbing, lasts between one and two hours, and may involve one or both sides of the head or the entire head. The headache is often accompanied by nausea and sensitivity to light and noise. A child may vomit one or more times.
●In adolescents, the headache pain usually begins gradually, intensifies over minutes to hours, and resolves gradually at the end of the attack. The headache is typically dull, deep, and steady at first, and may become throbbing or pounding if severe. Migraine headaches may be worsened by light, sneezing, straining, constant motion, physical exertion, or head movement. The pain usually lasts a few hours but can last up to 72 hours.
●Other symptoms can include passing out, abdominal pain, and motion sickness. Family members may have undiagnosed or misdiagnosed migraines (as an example, diagnosed with sinus headaches rather than migraines).
Aura — Some children with migraine headaches experience changes in their vision for several minutes before the headache. This is referred to as an aura. The aura may include flashing lights or bright spots, zigzag lines, or partial loss of vision.
Cluster headaches — Cluster headaches are severe, debilitating headaches that occur repeatedly for weeks to months at a time, followed by headache-free periods. Fortunately, cluster headaches are very rare in children younger than 10 years of age and only affect approximately 0.1 percent of children age 10 to 18 years. Cluster headaches are more common in men after age 20.
The headache is usually deep, excruciating, continuous, and explosive in quality. Cluster headaches commonly cause eye redness and tear production on the side where the pain occurs, a stuffy and runny nose, sweating, a pale appearance, and possibly drooping of the eyelid. The headache is usually short in duration (between 15 minutes and 3 hours). There are also shorter duration cluster headaches that have a similar quality and associated features but that last only last seconds to minutes.
Headaches can often be treated at home. If a child is otherwise well and does not have worrisome signs or symptoms, it is reasonable to treat the child before seeking medical attention.
When to seek help — If a child has one or more of the following, s/he should be evaluated by a healthcare provider before any treatment is given:
●If the headache occurs after a head injury
●If the pain is severe or there are associated symptoms, such as vomiting, changes in vision or double vision, neck pain or stiffness, confusion, loss of balance or unsteadiness, and/or fever (temperature higher than 100.4ºF/38ºC)
●If the headache awakens the child or occurs upon waking
●If headaches occur more than once per month
●If the child is younger than three years of age
●If the child has certain underlying medical conditions such as sickle cell disease, immune deficiency, bleeding problems, neurofibromatosis, or tuberous sclerosis complex
History and physical examination — In most cases, the cause of a child's headache can be determined with a complete medical history and physical examination.
In some cases, the provider will ask the parent/child to keep a headache diary for several months. A diary can provide detailed information about the time, date, and features of headaches.
Imaging tests — The need for an imaging test depends upon the individual child's signs and symptoms, physical examination, and medical history. However, most children with a headache who have a normal physical examination will not require an imaging test such as a CT scan (computed tomography) or MRI (magnetic resonance imaging). If a child has an abnormal neurologic examination, has a new severe headache, or has other worrisome signs or symptoms, an imaging test will usually be recommended and unless deemed emergent, an MRI is recommended in most cases.
The treatment of headaches depends upon the child's age, the type and frequency of headaches, and other characteristics.
Illness or injury-related headache treatment — A child who has a headache caused by an underlying illness or minor head injury can be treated similarly to a child with a tension-type headache (see 'Infrequent TTH' below). However, it is important to be aware of signs or symptoms that could indicate a more serious condition, which should be evaluated by a healthcare provider. (See 'When to seek help' above.)
Tension-type headache treatment
Infrequent TTH — Infrequent tension-type headache (TTH) is defined as occurring less than once per month. Children with infrequent tension-type headaches may be treated with an over-the-counter pain medication, such as children's acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin). Aspirin is not recommended in children who are less than 16 years old due to the risk of a rare but serious condition called Reye syndrome. The dose of acetaminophen and ibuprofen should be based upon the child's weight, rather than age.
Other suggestions include the following:
●Identify and reduce or eliminate any factor that causes or worsens headaches, based upon information from the headache diary (eg, stress, lack of sleep, dietary factors).
●Notify the child's healthcare provider if any warning signs develop, including fever, stiff neck, loss of vision, or double vision.
●Rest – Ask the child to lie down and relax, and apply a cool wet cloth to the forehead. Talk to the child to determine if he or she is worried or anxious about activities at home or school.
●Stretch and massage – Stretch and massage the neck muscles if they are tight or tender.
●Food – If the child has not eaten recently, offer a snack. Skipping meals can sometimes worsen a headache.
Frequent or chronic TTH — If a child has frequent or chronic TTH (ie, ≥15 days per month), the first line of treatment is an over-the-counter (OTC) rescue pain medication, such as children's acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin). Aspirin is not recommended in children who are less than 18 years due to the risk of a rare but serious condition called Reye syndrome.
To avoid medication-overuse headache (also called "rebound" headaches), OTC pain medications should not be used more than two days in a given week without the express recommendation of a clinician. In addition, the daily dose should not exceed that recommended by the manufacturer.
Programs that help to alleviate stress may also be helpful for children with chronic TTH. This may include psychological counseling, relaxation therapy, or biofeedback. Biofeedback teaches the child to voluntarily control certain body functions, like heart rate, blood pressure, and muscle tension.
If the headaches do not improve with rescue medication, the healthcare provider may recommend that the child be evaluated by a specialist (eg, neurologist). The specialist may recommend a medication, such as a small daily dose of a tricyclic antidepressant (TCA), such as amitriptyline (Elavil). The dose of TCAs used for treating chronic pain is typically much lower than that used for treating depression. It is believed that TCAs reduce pain perception when used in low doses, although the exact mechanism of their benefit is unknown.
Migraine headache treatment
General measures — Many triggers can bring on a headache attack or worsen a preexisting headache. The specific factors that trigger attacks can differ from one person to another. A partial list appears in the table (table 1). Children who have frequent or severe migraines should keep a record of their headaches in a headache diary. This can help to determine if a specific trigger can be avoided to prevent future headaches.
There are two types of migraine treatments: acute and preventive. Abortive treatments are given to treat the current migraine symptoms (eg, pain, nausea, etc), while preventive treatments are given to prevent migraines from developing.
Acute treatments — The first medication generally recommended to stop a migraine is an over-the-counter rescue pain medication, such as acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin). This should be given as soon as possible, at the first sign of the migraine.
If the child develops nausea or vomiting, a prescription medication may be given to relieve these symptoms. One of the most commonly recommended antinausea medications for children older than two years is promethazine (sample brand name: Phenergan). Promethazine may be given by mouth or as a suppository in the rectum.
If the headache does not improve or if the child begins vomiting before acetaminophen or ibuprofen is given, a medication called a triptan may be recommended. Several triptans are approved by the US Food and Drug Administration (FDA) for use in adults. Rizatriptan (sample brand name: Maxalt) is also approved for children ages 6 to 17, while almotriptan (sample brand name: Axert) and zolmitriptan nasal spray (sample brand name: Zomig) are approved for ages 12 to 17. The most common side effects of triptans are a feeling of jaw or chest tightness and mild sleepiness ("after Thanksgiving feeling"). Triptans can be taken with ibuprofen for a combined benefit. Parents should discuss the potential risks and benefits of triptans with their child's healthcare provider.
Preventive treatments — The safety and efficacy of preventive treatments for migraine headaches have not been well-studied in children. Several have been tested in small clinical trials but none have shown consistent benefit. Nevertheless, some experts have found the following medications to be helpful:
●Cyproheptadine (brand name: Periactin) is an antihistamine that is used for migraine prevention. It may be recommended for migraine prevention in young children. Side effects can include sleepiness and increased appetite.
●Propranolol (sample brand name: Inderal) is a blood pressure medication that is frequently given to prevent migraines in adults. It is sometimes recommended for prevention of migraines in children. The child's heart rate and blood pressure should be monitored during treatment, as both may be lowered by the medication. Propranolol should not be used by children with asthma or type 1 diabetes and may make teenagers feel depressed.
●Amitriptyline (brand name: Elavil) is a tricyclic antidepressant that, when given at low doses, can help to reduce the frequency, severity, and duration of migraine headaches. It is usually given at dinnertime to lessen morning sleepiness so that children may attend school. The dose may be increased slowly over time as needed.
●Antiepileptic medication such as topiramate (brand name: Topamax) and sodium divalproate (brand name: Depakote) are frequently given to prevent migraines in adults. Topiramate is approved by the FDA for the prevention of migraine in 12 to 17 year olds. The main side effects of topiramate are cognitive slowing, tingling, kidney stones, and weight loss. The main side effects of divalproate are weight gain, ovarian cysts, rash, and platelet dysfunction.
●Although scientific studies have not shown herb or vitamin supplements to be effective in all cases, some patients have found riboflavin or coenzyme Q10 to be helpful as a preventive treatment for migraines. These agents are unlikely to be harmful. Nonetheless, parents should talk to their child's healthcare provider before using this type of treatment.
The choice among these treatments will depend upon the age and characteristics of the individual child.
Menstrual migraine treatment — Some adolescent girls have migraine headaches around the time that their menstrual period begins. If the migraines occur infrequently, they are usually treated with an abortive treatment, as described above. (See 'Acute treatments' above.)
If menstrual migraines occur on a predictable schedule, a preventive treatment may be recommended. This is usually started a few days before and continues for a few days after the menstrual period starts. Preventive treatments may include a nonsteroidal antiinflammatory medication (eg, naproxen), a birth control pill, or a triptan. (See "Patient education: Headache treatment in adults (Beyond the Basics)".)
Cluster headache treatment — Cluster headaches are usually managed by a specialist (eg, neurologist). The treatment of cluster headaches in children is based upon treatments that have been successful in adults. Cluster headaches are poorly studied in children because they occur so rarely. (See "Patient education: Headache treatment in adults (Beyond the Basics)".)
Chronic headache treatment — Chronic headaches occur on ≥15 days per month. The treatment of chronic migraine or tension-type headaches usually centers on lifestyle changes. Since many children with chronic headaches overuse headache medications, it is important to discontinue any overused pain medications (eg, acetaminophen [sample brand name: Tylenol]) as quickly as possible. Management of chronic headaches requires a coordinated approach with the child's clinician and should be individualized according to the needs of the child; clear guidelines regarding the use of OTC medications should be discussed.
Lifestyle changes include drinking an adequate amount of fluids, reducing or eliminating caffeine, getting regular exercise, eating and sleeping on a regular schedule, and stopping smoking.
Some children with chronic headaches stop attending school or other normal daily activities. It is important to encourage the child to return to these activities as a part of treatment. If necessary, the child can be allowed to lie down in the school nurse's office for a brief period (eg, 15 minutes once daily) when headache pain is worst.
WHERE TO GET MORE INFORMATION
Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Headaches in children (The Basics)
Patient education: Headaches in adults (The Basics)
Patient education: Migraine headaches in children (The Basics)
Patient education: Closed head injury (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Headache causes and diagnosis in adults (Beyond the Basics)
Patient education: Headache treatment in adults (Beyond the Basics)
Patient education: Head injury in children and adolescents (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Headache in children: Approach to evaluation and general management strategies
Classification of migraine in children
Emergent evaluation of headache in children
Acute treatment of migraine in children
Pathophysiology, clinical features, and diagnosis of migraine in children
Tension-type headache in children
The following organizations also provide reliable health information.
●The Children's Hospital of Philadelphia
●The Nemours Foundation
(kidshealth.org/parent/general/aches/headache.html, available in Spanish)
- Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002; 59:490.
- Lewis DW, Dorbad D. The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations. Headache 2000; 40:629.
- Prensky A. Childhood Migraine Headache Syndromes. Curr Treat Options Neurol 2001; 3:257.
- Dyb G, Holmen TL, Zwart JA. Analgesic overuse among adolescents with headache: the Head-HUNT-Youth Study. Neurology 2006; 66:198.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.