When Should You Discuss Your Child's Headache With a Doctor?

Elizabeth Rende, DNP, of the CentraCare Neurosciences Headache Center was recently a guest on “Your Health” — a weekly radio program with KNSI’s Bob Hughes.

Prior to joining CentraCare, Elizabeth was an Assistant Professor at Duke University School of Nursing, the primary provider of care in the Duke Pediatric Headache Clinic and has authored articles about pediatric nursing and pediatric neurology. Among the topics discussed include what are common types, causes and remedies for head pain. You can listen to the full program here. Some of the content below has been edited for length and clarity.

Q: When you have a child who is experiencing headaches, how do you get him or her to open up and start talking about their pain?

Elizabeth: Headaches are extremely common. Up to 75% of children will have at least one headache by the time they're a teenager, but fortunately many of those children don't need advanced consultation or a further evaluation.

What’s really challenging is the younger child who may have difficulty telling you about their headache. You have to rely on parents who tell you about their child's behavior when he or she has a headache. Or the teachers who send the child with a headache home because he or she just can't pay attention or remember things. In particular, migraine headaches are often associated with vomiting in early childhood. That's an obvious symptom to report to a health care provider. Whether a child's four or five years old or 15 years old, recording his or her health history is essential. If we don't ask the right questions, we are not going to get the answers that we need.

Q: Is there a commonality when it comes to a pediatric head pain? Is it similar to that of an adult’s head pain?

Elizabeth: We know that kids are not little adults, so I think they do have some unique qualities to their headaches. But children also have migraine headaches and they can present with the same symptoms as adults with migraine headaches.

Q: Are there other kinds of head pain that a child will experience?

Elizabeth: Just a plain headache. Unfortunately, the diagnostic criteria call it a tension headache, but we just call it a "regular" headache compared to a migraine headache. But kids can also have headache associated with illness and that's very, very common. They may have strep throat, but they may have a headache that goes along with that. Even a gastrointestinal illness with fever may be associated with headaches.

Q: What kind of patients do you see?

Elizabeth: Many parents are seeking additional recommendations when a headache doesn't get better. Parents are noticing their child complaining of more and more headaches. Children with headaches should be evaluated if they're missing school or if their school performance is deteriorating. If they are not able to play basketball, gymnastics or if it's really affecting their quality of life. They may have difficulty with sleep. They may get behind in their work.

Q: Can younger children get migraine headaches?

Elizabeth: Children as young as two or three years old may begin having migraine headaches, but you can imagine that it is much harder to get an accurate history and to determine exactly what kind of headache it is. Or, more importantly, to exclude other causes of headache that we wouldn't want to miss.

Q: What is the difference between a “regular” headache and a migraine headache?

Elizabeth: The International Classification of Headache Disorders provide the diagnostic criteria, which are a list of symptoms that need to be present to designate a specific type of headache. Migraine headache is a headache of moderate to severe intensity associated with nausea and/or vomiting, light sensitivity or sound sensitivity and aggravated by physical activity. That's what makes a headache a migraine versus a tension type headache.

A tension type headache can be associated with migraine-like symptoms such as light or sound sensitivity. Kids can be nauseated with a tension type headache, but they probably aren't going to vomit. The key difference between the migraine headaches and the tension type headache is that kids with "regular" headaches can play basketball, go play soccer, go to gymnastics, stay in school, etc. Children with a migraine headache are usually debilitated and must go home and sleep. They will also have trouble concentrating and learning, being able to do what they need to do — especially at school. Physical activity will worsen the migraine headache.

Q: How can a type of migraine be tested?

Elizabeth: The science of migraine has defined a specific process of pain propagation that happens during a migraine headache. We know that keeping track in a calendar is super easy and really important for us — to help us identify possible triggers or other contributors to headache. What is most helpful is noting the context in which the headache occurs. For example, is it happening Sunday night before going back to school on Monday? Or after a stressful exam series? Parents should keep track of the onset of a headache, when it goes away and how they treat the headache.

A primary migraine trigger is stress. This includes even good stress (such as a party, family gathering, vacation or holiday). Food triggers are not as common as we once thought. While a good eye exam is important, it's not likely to be the primary cause for headache, especially migraine.

It is not uncommon to learn that other family members in your extended family have migraine headaches too. They are said to "run" in families. 

Q: Do migraine headaches appear more in boys or girls?

Elizabeth: Both boys and girls share an equal amount of headache complaints while in elementary school. In middle school, boys get headaches less often. And, as they go into high school, girls' headaches tend to be more frequent. But migraine headache is a lifelong disorder. It is not something that a child outgrows. His or her headache pattern may change, the severity may change throughout the course of life, but he or she has a "migraine brain" throughout life.

Q: How about hormonal changes that are going through teenagers? Can that produce headaches?

Elizabeth: Absolutely. And that is what is largely responsible for why teenage girls have more headaches. Male hormones do not make a big difference in triggering migraine headache, it's a different story in girls.

Q: Are there common triggers for migraine headaches?

Elizabeth: Stress is probably the number one trigger for both tension type and migraine headaches. Dehydration is also a big trigger. Poor sleep habits now appear to affect chronic illness of all sorts, not just headache.

Q: What happens when parents talk to you about headaches? Are there a series of tests that you automatically order?

Elizabeth: If a child has a first time "super bad" headache, he/she is likely to end up in the emergency room, which is the right place. It's frightening for parents and the child. At that time, the emergency room provider may choose to do an imaging study to make sure they're not overlooking the cause for that first-time headache. This is usually a CT of the head because it can be done quickly, usually without sedating the child and normal results can be very reassuring the parent or caregiver and the child.

On the other hand, children may come into the emergency room with a typical migraine headache. While parents may expect imaging, if a child has had headaches for a while, there is documentation of normal physical and neurological exams and he or she has had a normal neurological exam in the emergency room — they're not necessarily going to get imaging. This is up to the examining provider. The American Academy of Neurology recommends that if this headache is similar to previous headaches, they have had headaches for six months or longer, they have a normal neurological exam and no "red flags" (or warning signs) in their medical history — then a CT scan is not needed. This also safeguards the child from unnecessary radiation exposure. 

Q: What could a parent do for son or daughter who may be having some severe headache issues?

Elizabeth: First and foremost, the parent or caregiver should seek their primary care provider's advice. Over-the-counter medicine is certainly appropriate unless there is a reason why they cannot take these medications. Acetaminophen and ibuprofen are perfectly fine, and their primary care provider can tell them the appropriate dose. Aspirin is no longer recommended; it can cause stomach upset and can also contribute to serious medical complications if given in the context of a viral illness. 

Q: Are there other types of treatments for headaches that can work with kids?

Elizabeth: There are complimentary and integrative medicine approaches. These are often recommended in addition to other treatment plans. Complimentary approaches can include cognitive behavioral therapy (CBT), massage, yoga, mindfulness, biofeedback and even hypnosis. This group of adjunct therapies may provide additional relief from headache pain. 

Q: How do parents know when it is time to bring their kids to see their primary care provider for headaches? And then how does that doctor know when it's time to make the referral to you?

Elizabeth: Parents should consult their primary care provider if the headache is causing significant disability (missing school, unable to participate in family and sports activities) or growing concern about the headache, whether it's coming from the parents, caregivers or the child himself/herself. Children can become very frightened about the meaning of headaches. Consulting their primary care provider is the first stop.

The the primary care provider may make a neurology referral for additional evaluation regarding the type of headache and recommended treatment. Watching waiting may be suggested, with parents documenting headaches on a calendar for a period of time. Over-the-counter medicines may be recommended. If a neurology referral takes place and headaches are being well managed, we will likely ask the patient to follow up with their primary care provider — as they are the primary leader in the child's healthcare.