Managing chronic headaches in children

Jenny wrote in about her son, who has a lot of headaches: “My 12 year old son gets them pretty much every day, and this has been going on for six months. He missed a lot of school, and now is starting to get them again in the summer. The doctor ordered a CT scan which didn’t show anything. What can this be? Could it be sinuses?”

Headaches are common in children. They’re usually “primary” headaches — meaning they’re not caused by anything specific, and they’re not associated with any specific medical condition. They’re just headaches.

Kinds of “primary” headaches in children include:

Migraine.  Maybe the most common of the more-severe headaches. In children they’re often bilateral and fairly brief. Sometimes they’re accompanied by vomiting, or are worsened by lights or sound; often the best “cure” is to go to sleep. Migraines often run in families.

Tension. These create a band-like, or squeezy feeling in the head, and aren’t usually severe. Yes, kids of all ages get tense.

Chronic daily headache. This sounds like Jenny’s son. They often occur on top of occasional more-severe headaches, like migraines.

The general principles of chronic daily headache:

  • Avoid daily Advil or Tylenol. If you use those more than 3 days a week, you will perpetuate the headaches. I know this sounds odd, but I promise it is true.
  • Try to maximize healthy lifestyle. Good regular sleep, diet, avoiding a lot of preservatives and chemicals, getting regular exercise. Again, I know this sounds odd, but it does help.
  • Try not to miss school. That inevitably makes headaches worse.
  • Consider massage/yoga/relaxation therapy.
  • If there is an overlay of depression/anxiety/mood issues, deal with that. There is often a psychological component, either contributing to the headaches, or being caused by the headaches and missing school and activities.
  • Consider a daily medicine to control the headaches. Not painkillers, but other kinds of medicines that prevent headaches. You will need a physician’s guidance if daily medication is needed.

About CT scans and headaches: they’re almost never necessary for chronic, ongoing, stable headaches (or headaches that come and go in a stable pattern.) Imaging is really only useful for acute, worse-in-a-lifetime headaches, headaches associated with other symptoms (like seizures or neurologic problems), or progressive headaches that are getting worse and worse. CTs (or MRIs) are completely unnecessary in the workup of most children with headaches, and will sometimes give misleading results that lead to wild goose chases and misery.

Another headache myth: Most people out there who think they’ve got sinus headaches have been misdiagnosed.  Recurrent “sinus” headaches are genuinely uncommon. When they do occur, they’re associated with persistent nasal congestion and cough that precede the headache. Migraines themselves, which are far more common than recurrent headaches from sinusitis, can cause nasal or sinus symptoms that begin about the same time as the headache. It’s unlikely that Jenny’s son has headaches from sinus disease without other obvious persistent sinus symptoms, especially with a normal CT scan.

Yet another headache myth to dispel: vision problems rarely cause recurrent headaches in kids. Some people who are nearsighted will squint, and by the end of the day will develop tension-like pain from tightening up the muscles of their face and scalp, but that really is uncommon.

Headaches in children are common, and most commonly are caused by a minor infection, dehydration, hunger, or stress. If they’re recurrent, they’re likely to be one of the common primary headaches, like tension headaches or migraine or chronic daily headache. Headaches that are progressive (worsening), or associated with other prominent or worsening symptoms, need an urgent medical evaluation, but those are fortunately rare. More typically, headaches just need to be treated like, well, headaches.

Don’t forget the simple stuff: rest, a kiss on the forehead, a cool compress, something to help relax. In the long run, those are probably better headache remedy for children than any medication.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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  • NPPCP

    What a great great article. I printed it off and saved it in my patient education folder. Just gave out the first one and mom loved it! I have a private NP family practice clinic and I am grateful for pediatricians!

  • Jess

    I’m glad you mention dehydration, since that’s what the chronic headaches of a colleague’s young daughter were finally traced back to (thanks to a very caring and unusually perceptive school nurse).

    The girl was developing headaches in the afternoon, some of them requiring a stint lying down in the nurse’s room, some severe enough to see her sent home from school. After talking to her enough during the stints where she was sent to rest in the nurse’s office, the nurse learned that the girl had developed a terror of having to use the restrooms at her new school, and had come up with a solution that worked beautifully for her: she simply wouldn’t drink anything all day until she was safely home from school, so she wouldn’t need to use the school restrooms. Leading to dehydration, leading to headaches.

    Working through her fears of going to the restroom at school freed her up to drink normally, and the headaches went away never to return.