A neurologist talks about kids and headaches

It's not uncommon for a child to complain of a headache. But what should a parent do? When should you worry? What are features that are cause for concern and should prompt a call to the pediatrician, or even a trip to the emergency room? For kids with headaches, do they necessarily need to take medication, or are there other nondrug treatments that may be just as effective?

When to call your pediatrician

The cardinal rule for thinking about headaches is "first or worst." In practical terms, if your child has never had a headache before, you need to evaluate carefully.

• Did he have any recent head trauma, such as a fall or a sports injury?
• Was she sick with a bad virus?
• Is he vomiting or does he have a fever?
• Is she unable to walk, talk, and eat normally?

If the answer to any of these questions is "yes," it's time to call the pediatrician. A concussion, a severe infection, or even a rare but more ominous cause for a headache could be the trigger. Many people worry about a brain tumor, but this is very unlikely. You should never be alone with worry about your child's headache, and your pediatrician can help to steer you toward the best treatment.

Kids can experience migraine headaches

Children can and do get migraine headaches. The rate is estimated at 5.5%, but underdiagnosis may falsely lower the number. Think about migraine in particular if a parent has migraines, as there is a strong genetic link. Kids' migraines are different than adults': the pain can be on both sides of the head and not last as long. But just like in grownups, kids can be totally incapacitated with a migraine, with profuse nausea and vomiting and the need to lie in a dark room. It's not possible to make a diagnosis after just one headache, though. Kids need to have at least two episodes to be diagnosed with migraine. Ibuprofen can be a very effective treatment once a headache hits, but don't forget about ice, which can also relieve pain and decrease inflammation. A bag of frozen peas is lightweight, and the child can position it comfortably over his or her head.

There is a migraine-specific class of drugs called triptans that is used to stop migraines when they start. One formulation called zolmitriptan is approved for use in children. It comes in a nasal spray so it can be used for kids who can't swallow pills. For children with frequent migraines, it may be necessary to try to prevent them. Certain medications are used for both children and adults, such as amitriptyline and topiramate. A recent study found that combining amitriptyline with a form of cognitive behavioral therapy (a type of mind-body work that helps to change a person's response to pain and anxiety) can be more effective than the drug alone. And some children will respond to cognitive behavioral therapies alone as preventives. Health insurance often covers these treatments, so be sure to ask about options.

The more typical kid headache

Tension-type headaches are more common. The old name for these was "hat band headache" and that's often what the pain is like. Kids describe pressure around their forehead or entire head, not the throbbing of a migraine. Often they can function, eat, go to school, and even play sports although they don't feel well. Ibuprofen may help, and relaxation and fluids may be adequate to treat a tension-type headache.

Lots of parents are concerned about screen time triggering headache, and it's a valid concern. Bright lights and screens definitely can trigger migraines in susceptible children and adults, but staring at a computer, phone, or iPad can trigger a headache for anyone if used for too long. Encourage limits on screen time, taking breaks, and getting up to stretch when working or playing games.

It's important to ask about stress and anxiety when evaluating your child's headache. School-avoidance headaches can be tough to diagnose. Careful questions and discussion with teachers and guidance counselors may help a parent figure out if a headache is actually a way for a child to avoid bullying or a difficult situation at school. This hopefully leads to intervention and resolution of the triggers.

The bottom line

If your child tells you she has a headache, take her seriously. Ask questions about type of pain, other symptoms, and recent events. Enlist your pediatrician to help make the right diagnosis. It may be useful to see a pediatric neurologist. And if the child has a fever, can't stop vomiting, or tells you he has double vision or trouble moving his arms or legs, go directly to the emergency room. Chances of this are very rare. Most headaches are very treatable.

References

Pediatric migraine. Medscape Neurology Clinics, 2009.

Trajectory of Improvement in Children and Adolescents With Chronic Migraine: Results From the Cognitive-Behavioral Therapy and Amitriptyline Trial. Journal of Pain, June 2017.