Patient education: Headache in children (Beyond the Basics)

HEADACHE OVERVIEW — Headaches are a common complaint in children and adolescents, occurring in up to 75 percent of school-aged children. The frequency of headaches is greater in adolescents than in younger children. There are many possible causes of headaches, from common and nonharmful to rare but serious conditions.

This topic reviews the causes, evaluation, and treatment of headaches in children and adolescents. 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)".)

HEADACHE TYPES — Headache is a symptom and not a disease or disorder itself. Thus, there can be numerous possible causes of headaches in children. The most common causes include the following:

●Migraine

●Tension-type headache

●As a symptom associated with viral or upper respiratory infections (including ear infections, the common cold, allergies, sinus infections, strep throat)

●As a consequence of a minor or moderate head injury

Only a small minority of children with headaches have a serious underlying cause, such as a brain tumor or life-threatening infection.

TYPES OF HEADACHES — The symptoms in a child depend upon the child's age, the type of headache, and the underlying disorders. Headaches are generally classified as primary (ie, the headache symptom itself is the disease or disorder) or secondary (ie, the headache is a symptom of a separate underlying disease or disorder). The most common types of primary headaches in childhood are migraine and tension-type headaches, while the most common secondary headaches are associated with an infectious illness or are related to head injury.

Infection or injury-related headaches

●Infections – Headaches may be an associated symptom of a systemic infection or may be directly due to a localized infection of the brain or surrounding tissues. A key feature of headache related to an infection is that when the infection gets better, the symptoms of headache should get better, too. If this does not happen, then an alternative explanation for the headache must be investigated. (See 'Headache evaluation' below.)

•Viral or upper respiratory infections – 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 and occurs at the same time as the other symptoms of the illness.

•Infection of the brain or surrounding tissues – Infections of the brain (encephalitis) or surrounding tissues (bacterial or viral meningitis) are serious and life-threatening infections that can cause headache. They are usually accompanied by other symptoms, including:

-Fever

-Sensitivity to light

-Neck stiffness

-Nausea/vomiting

-Confusion

-Lethargy

-Seizures

-Irritability

(See "Patient education: Meningitis in children (Beyond the Basics)".)

●Head injuries – Head injuries (eg, concussion), which can occur at home, school, or while playing sports, are a common cause of headaches. Typically, these headaches last a few hours, with 80 percent getting better within 7 to 10 days. 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 health care provider. (See "Patient education: Head injury in children and adolescents (Beyond the Basics)" and 'When to seek help' below.)

If the headache persists after all other symptoms of a head injury have resolved, the child may have a primary headache disorder (discussed below). (See 'Primary headache disorders' below.)

Primary headache disorders

Tension-type headaches — Tension-type headaches (TTH) cause a pressing tightness that is diffuse and located around both sides of the head or neck. The pain is usually mild to moderate, does not throb, and may last from 30 minutes to several days. Some children with TTH have nausea and are sensitive to light or noise (although International Classification of Headache Disorders criteria allow only one of these three symptoms), or feel lightheaded or tired. TTH does not usually cause vomiting and is not worsened by normal daily activities, although the child or adolescent may resist participating in activity. Children with TTH may not be brought to medical attention because the headaches are usually mild.

Migraine — Migraine is a disease/disorder, not an event, with the symptoms of migraine varying with age. During adolescence, the symptoms become more typical of the symptoms of migraine in adults.

Migraine is a disorder of episodic attacks, with headache being one of the symptoms. Migraine can include other episodic disorders (eg, childhood periodic symptoms or episodic symptoms associated with headache).

●In infants, episodes of colic or intermittent torticollis (twisting of the neck to one side) may be early signs that the child has migraine.

●Toddlers may have episodes during which they are pale and/or less active than usual. At times the 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 (acute intermittent vertigo).

●School-aged children may be better able than toddlers to describe the headache and associated feelings. The pain of migraine is usually pounding or throbbing – although the children may need to demonstrate this or draw the symptom. The pain most often involves the forehead. It lasts more than an hour and can last a whole day. The headache is often accompanied by nausea and sensitivity to light and noise. The child may vomit one or more times. Parent or caregiver observation of symptoms (eg, nausea/vomiting, sensitivity to light and noise) is permitted as part of the diagnostic criteria.

●Adolescents may recognize early neurologic signs of an attack (aura) or the more minor symptoms that precede an attack (prodrome). This helps them describe that the pain of the headache attack intensifies over minutes to hours. If severe, the headache may build rapidly to throbbing or pounding over 30 minutes. Multiple triggers have been suggested for migraine, including bright light, sneezing, straining, constant motion, physical exertion, head movement, and eating certain foods. The reliability of these triggers, however, is inconsistent. The pain of migraine 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 migraine (as an example, diagnosed with sinus headaches rather than migraine).

●Aura – Some children with migraine experience changes in their vision, tingling and numbness, or difficulty talking (dysphasia) for several minutes (5 to 60) before onset of the headache. These neurologic symptoms that precede the headache are referred to as an "aura." The aura may include flashing lights or bright spots, zigzag ("fortificatia") lines, or partial loss of vision (scotomas); tingling starting in the fingers and moving up the arm to the face with numbness; or knowing what they want to say, but unable to get the words out. Auras should include a positive symptom (eg, flashing lights, bright spots, tingling) and not just a blurring of vision, difficulty focusing, or numbness.

Cluster headaches — Cluster headaches are severe, debilitating headaches that occur repeatedly for weeks to months at a time, followed by headache-free periods. They are one of a group of disorders termed trigeminal autonomic cephalalgias (TACs). Fortunately, cluster headaches are very rare in children younger than 10 years of age and only affect up to 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 include autonomic changes, such as eye redness and tear production on the same side on which 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 seconds to minutes.

HEADACHE EVALUATION — Primary headache attacks can often be treated at home. If a child is otherwise well, does not have worrisome signs or symptoms, and has a history of recurrent headaches, it is reasonable to treat the child before seeking medical attention.

When to seek help — Children with one or more of the following should be evaluated by a health care provider before any treatment is given:

●If the headache occurs and persists after a head injury

●If the pain is severe or there are associated symptoms, such as new onset of vomiting with a headache, changes in vision not due to an aura, double vision, neck pain or stiffness, confusion, loss of balance or unsteadiness, and/or fever (temperature higher than 100.4°F/38°C)

●If the headache awakens the child or occurs upon waking on a near-daily basis

●If headaches occur more than once per month

●If the child or adolescent is missing school, home, or social activities on a regular basis

●If the child is younger than six 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 by obtaining a complete medical history and physical examination. Imaging studies usually are not necessary.

In some cases, the provider will ask the caregiver/child to keep a headache diary for several months. A diary can provide detailed information regarding the time, date, patterns, 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 an MRI (magnetic resonance imaging) or a CT (computed tomography) scan. 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. An MRI is preferable to a CT scan in most cases, but a CT scan may be recommended if the imaging examination is urgent or the MRI is not available.

HEADACHE TREATMENT — The treatment of headaches depends upon the child's age, the type and frequency of headaches, and other factors.

Illness- or injury-related headache treatment — A child who has a headache caused by an underlying illness or minor head injury should have the underlying illness treated. The headache can be treated similarly to that in a child with a tension-type headache (TTH). (See 'Infrequent TTH' below.)

However, it is important to be aware of signs and symptoms that could indicate a more serious condition, which should be evaluated by a health care 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 (OTC) 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 (10 to 15 mg/kg per dose) and ibuprofen (7.5 to 10 mg/kg per dose) 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, excess screen time, dietary factors). Cognitive behavioral therapy (CBT) and maintenance of healthy habits are helpful in reducing or eliminating factors that cause or worsen headaches.

●Notify the child's health care provider if any warning signs develop, including fever, stiff neck, loss of vision, or double vision.

●Rest – Ask the child to lie down, relax, and apply a cool wet cloth to the forehead. Talk to the child to determine if they are worried or anxious about activities at home or school. This is only a temporizing measure. Returning to normal function as soon as possible is a goal of treatment.

●Stretch and massage – Stretch and massage the neck muscles if they are tight or tender. However, this may worsen the headache in some children with allodynia (experiencing pain from stimuli that do not typically cause pain [eg, brushing the hair]).

●Food – If the child has not eaten recently, offer a snack. Skipping meals can sometimes trigger or worsen a headache.

Frequent or chronic TTH — If a child has frequent or chronic TTH (ie, ≥15 headache days per month), the first line of treatment is an 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 headaches (also called "analgesic rebound" headaches), OTC pain medications should not be used more than two to three days in a given week without the express recommendation of a clinician, as this may worsen the headaches. 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 (headaches >15 days per month for at least three months). This may include psychologic counseling, relaxation therapy, biofeedback, and CBT. Biofeedback teaches the child to voluntarily control certain body functions, including heart rate, blood pressure, and muscle tension. CBT is more extensive but may have longer term benefits.

If the headaches do not improve with rescue medication, the health care provider may recommend that the child be evaluated by a specialist (eg, neurologist). The specialist may recommend a medication, such as a tricyclic antidepressant (TCA). The most commonly prescribed TCA for headaches is amitriptyline (sample brand name: Elavil). The dose of TCAs used for treating chronic pain is typically lower than that used for treating depression. It is believed that TCAs reduce pain perception when used in low doses, although the mechanism of their benefit is unknown.

Migraine treatment

General measures — Although many triggers have been suspected to induce, promote, or sustain an attack of migraine, the specific factors that trigger attacks can differ from one person to another and may be inconsistent between attacks [1]. Mobile phone apps can closely track potential triggers to help identify specific triggers for individual patients [2]. A partial list of potential triggers appears in the table (table 1). Children who have frequent or severe attacks should keep a record of their headaches in a headache diary. This can help to determine if a specific pattern or exposure can be avoided to prevent future headaches.

There are two types of migraine treatments: acute and preventive. Acute treatments are administered to treat the current migraine attack symptoms (eg, pain, nausea, etc), while preventive treatments are given to prevent attacks of migraine from developing.

Acute treatments — The first medication generally recommended to stop an attack of migraine is an OTC 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 attack. Studies have suggested that ibuprofen is superior to acetaminophen in stopping an acute migraine attack.

If the headache does not improve or if the child begins vomiting before acetaminophen or ibuprofen is given, then 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 that appears to be synergistic. Caregivers should discuss the potential risks and benefits of triptans with their child's health care provider.

Neuromodulator devices (eg, conditioned pain modulation, vagal nerve stimulation) have been approved by the FDA for the acute treatment of adolescents with migraine [3]. Devices that have been approved include Nerivio, GammaCore, and Cefaly.

Other categories for acute treatment of attacks that have been approved for adults (>17 years old) include calcitonin gene-related peptide (CGRP) antagonists (called "gepants") and the serotonin receptor antagonist 5-HT1F (called "ditans"). Studies of their safety and efficacy in children and adolescents are ongoing.

Preventive treatments — Evidence regarding the safety and efficacy of preventive treatments for migraine is limited. Several medications have been tested in clinical trials, but none have shown consistent benefit over placebo (a sugar pill). Nevertheless, some experts have found the following medications to be helpful:

●Cyproheptadine (brand name: Periactin) is an antihistamine that is used for prevention of attacks of migraine. It may be recommended for prevention in young children. Side effects can include sleepiness and increased appetite. Increased appetite may cause substantial unwanted weight gain, which may limit the use of cyproheptadine in children older than 10 years.

●Propranolol (sample brand name: Inderal) is a blood pressure medication that is frequently prescribed to prevent attacks of migraine in adults. It is sometimes recommended for prevention of attacks of migraine 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 (sample brand name: Elavil) is a tricyclic antidepressant that, when given at low doses, can help to reduce the frequency, severity, and duration of headaches. Its most common side effect is sleepiness. For this reason, it is usually given at dinnertime or bedtime to lessen morning sleepiness so that children may attend school. The dose may be increased slowly over time as needed.

●Antiepileptic medications such as topiramate (brand name: Topamax) and valproate (brand name: Depakote) are frequently given to prevent attacks of migraine in adults. Topiramate is approved by the FDA for the prevention of attacks of migraine in 12 to 17 year olds. The main side effects of topiramate are cognitive slowing, tingling extremities, kidney stones, and weight loss. The main side effects of valproate are weight gain, ovarian cysts, rash, and platelet dysfunction.

●Although scientific studies have not validated the effectiveness of herb, mineral, or vitamin supplements, some patients have found supplemental magnesium, riboflavin, or coenzyme Q10 to be helpful as a preventive treatment. If taken in moderate doses, these agents are unlikely to be harmful. Nonetheless, caregivers should talk to their child's health care provider before using this type of treatment.

●A large study regarding prevention of the attacks of migraine in children and adolescents has demonstrated that amitriptyline, topiramate, and placebo are all effective in preventing attacks, but none is superior.

●CBT has been demonstrated to be effective in preventing frequent attacks in children and adolescents with chronic migraine. This is typically a four-to-six week course that includes biofeedback, assisted relaxation training, adherence management, reduction of negative thoughts, and promotion of positive health activities.

●CGRP monoclonal antibodies have been approved for the prevention of the attacks of migraine (both chronic and nonchronic) in adults; studies in children and adolescents are ongoing.

CGRP antagonists ("gepants") have been approved for the prevention of attacks of migraine in adults. Studies are being initiated for children and adolescents.

●Devices that are being investigated for the prevention of migraine in children and adolescents include transcutaneous electrical nerve stimulation (brand name: Cefaly), vagus nerve stimulation (brand name: GammaCore), transmagnetic stimulation (brand name: eNeura), and conditioned pain modulation (brand name: Nerivio). Nerivio and GammaCore are approved for use in adolescents. Cefaly is available over the counter in the United States.

The choice among these treatments will depend upon the age and characteristics of the individual child.

Menstrual migraine treatment — Some adolescent females have headaches around the time that their menstrual period begins. These have been termed menstrual-related migraine. If the attacks occur infrequently, they are usually treated with an acute treatment, as described above. (See 'Acute treatments' above.)

If the attacks of menstrual-related migraine occur regularly, an intermittent preventive treatment may be warranted. This is usually started a few days before and continues for a few days after the menstrual period begins. Preventive treatments may include a nonsteroidal anti-inflammatory 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 or headache medicine specialist). 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 ≥15 days per month. The treatment of chronic migraine or chronic tension-type headaches is usually multimodal and includes preventive treatment, healthy lifestyle adjustment, and CBT.

Many children with chronic headaches overuse acute medications, and this overuse may play a major role in causing their chronic headaches. Therefore, it is important to discontinue any overused pain medications (eg, acetaminophen [sample brand name: Tylenol], ibuprofen [sample brand names: Advil, Motrin]) or prescription medications (such as the triptan class of medication) as quickly as possible. Overuse is defined as more than 15 days per month of OTC pain relievers such as acetaminophen, aspirin, and nonsteroidal anti-inflammatory medications (eg, ibuprofen) or more than 10 days per month of prescription or a combination of pain relievers (including agents such as Excedrin, which contains acetaminophen, aspirin, and caffeine).

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 acute medications should be discussed.

Lifestyle changes are often necessary to terminate chronic headache. These include drinking an adequate amount of fluids, eating a healthy diet, reducing or eliminating caffeine, getting regular exercise, eating and sleeping on a regular schedule, and refraining from smoking.

Prevention therapies are usually indicated if the headaches are occurring more than one to two times per week. This may include medications such as antidepressants – especially tricyclic antidepressants, antiseizure medications (such as topiramate [brand name: Topamax] or valproate [brand name: Depakote), blood pressure medications (such as beta-blocker or calcium channel blockers), or antihistamines. One study demonstrated that amitriptyline, topiramate, and placebo were all effective in preventing children's migraines [4].

One of the more effective treatments for chronic migraine is CBT combined with amitriptyline. Most children can benefit from this within four to six weeks and will have a sustained positive result [5].

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 health care 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 website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care 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: Migraines in children (The Basics)
Patient education: Head injury in adults (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
Types of migraine and related syndromes in children
Emergency department approach to nontraumatic 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.

●Cincinnati Children's Hospital Medical Center

(www.cincinnatichildrens.org/health/h/headaches)

●The Children's Hospital of Philadelphia

(www.chop.edu/conditions-diseases/headaches-children)

●The Nemours Foundation

(www.kidshealth.org/en/parents/headache.html, available in Spanish)

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ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Andrew G Lee, MD, who contributed to an earlier version of this topic review.