Kristen Padulsky, CPNP is one of Floating Hospital for Children’s pediatric neurology specialists who have a particular focus on headaches. Here, she answers some common questions about pediatric headaches.
Q: How common are headaches in children?
A: They are surprisingly common: headaches are the number one complaint for which children are referred by their pediatricians to our pediatric neurology clinic. Children may begin experiencing headaches as early as three years of age or their onset can begin in the teen years—puberty can be a trigger for migraines. It’s important for parents to know that the vast majority of headaches are “primary” headaches, meaning they are an ailment of themselves and are not a symptom of another illness such as a tumor or a brain malformation. Especially for children who are developmentally appropriate, headaches almost always fall into one of two categories: tension headaches and migraine headaches.
Q: What are the symptoms of tension and migraine headaches in children—are they similar to adult symptoms?
Symptoms are often similar to adult headaches. Tension headaches typically involve pain which is a pressing or squeezing feeling and not associated with nausea/vomiting or sensitivity to light/sound. They often occur as a result of stress and may cause kids to be irritable. Migraines often involve nausea or sensitivity to light and sounds. They usually feel pulsing and are made worse with physical activity.
Q: If my child has a headache, how should I respond?
A: Many headaches respond well to children’s ibuprofen (Motrin), and for a child who gets only an occasional headache that would typically be the first choice of treatment. Encouraging the child to rest and drink some fluids may also be helpful—sometimes the best cure for a headache is a nap. If a child is having several headaches a week that don’t seem to be related to other illnesses or medications, is missing more than one or two school days a month and is opting to sit out activities he or she enjoys because of headaches, it’s probably time to visit the pediatrician. The pediatrician and parents can determine whether the child should be seen by a neurologist. Typically, we see children in neurology when headaches are impacting their normal activities and school or if the pain is not being controlled with first line medications. Again, parents should not assume that a referral to a pediatric neurologist means that their pediatrician suspects that their child may have a brain tumor—we’re experts at helping kids and parents learn how to manage headaches.
Q: What are some of the causes or triggers of primary headaches in kids?
A: Just like adults, some kids are more sensitive to stress, schedule and sleep disruptions and certain ingredients in foods than others. We often give new patients a calendar to keep track of what’s going on in their lives that might give us clues to their headache triggers. We ask patients and parents to keep track of how they slept, what foods they ate and how often they’re eating, changes in their family situation, and changes at school. Processed foods, particularly those high in monosodium glutamate (MSG), nitrates, and sodium can trigger headaches in some kids, and skipping meals can also be a trigger. Irregular bedtimes, lack of sleep and stress are common causes. Parents should look for patterns that seem to occur in concert with the onset of headache symptoms. If your child gets a headache every time he has a baseball game, for example, he may be responding to the pressure to perform. Ask your child what feelings he or she may have been having before the start of their headache—were they worried or upset, and if so, why?
Q: For a child who is having many headaches, what types of treatments do you recommend?
A: Of course it depends on the child and the extent to which the symptoms are impacting their life, but we have both medical and behavioral interventions to offer—and sometimes a combination of both is what’s needed for children with truly persistent and severe headaches.
Regarding medications, a child should not be taking ibuprofen every day because of the possible gastric side-effects and because people can actually experience what are called rebound headaches from medication overuse. If a child is taking an over-the-counter medication for headaches more than once or twice a week, a preventative medication should be considered. There are many options to choose from based on a child’s age, size, developmental stage and many other factors. The length of time a child may be treated with medication varies greatly.
On the behavior modification side, we often work with families to examine and shift a child’s schedule and habits. Often children who experience many headaches aren’t getting adequate rest, and they may need an earlier bedtime and better bedtime rituals to signal to their bodies that it is time for sleep. Exercise can be enormously helpful in reducing stress and reducing the frequency of headaches. School aged children can learn and benefit from many of the same relaxation techniques that adults use—deep breathing, and even meditation and yoga. Limiting screen time is also crucial in cutting back on headaches. Children should minimize their time in front of tv, videogames and computers and should take frequent breaks when participating in these activities. I caution older children and teenagers to be wary of their caffeine intake which can trigger headaches and interfere with sleep.
Q: When a child is referred to pediatric neurology for headaches, what is the typical examination like?
A: I will take a thorough history of the child’s experience with headaches and conduct a neurological exam. Although children may be apprehensive before the visit, the neurologic exam does not hurt and most children think the exam is fun because it involves simple tests for coordination, balance and strength among other things. Parents often ask if an MRI will be performed as part of a routine evaluation. Not all children require an MRI of their brain, the history and physical exam often gives us enough information to make a diagnosis. If we have further questions, we may consider an MRI or other testing.
Q: If a child’s headaches are neither tension headaches nor migraines, what are some possible causes?
There are many reasons why children get headaches. Trauma, like a concussion, can cause headaches in some children. While we certainly see concussions in athletes, concussions can occur in many settings when children are playing. It’s important to think carefully about possible events that may have resulted in the headache. Other causes of headache can include things that put an increased pressure on the brain such as an increase in cerebral spinal fluid or tumor. However, these are much less common and are usually associated with other symptoms or exam findings.