By Dr. Nancy Shan, pediatric resident at CHOC
Headache complaints can be bewildering and frightening to many parents. Most are caused by a benign (simple) problem or primary headache disorder. Very rarely are headaches a sign of a serious underlying condition. Headaches are more common in boys than girls under 7 years of age, but the gender prevalence changes around puberty.
Headaches are often referred to as either primary or secondary. Primary headache disorders include migraines, tension headaches and chronic headaches. Tension headaches are the most commonly diagnosed type in children. Chronic daily headaches are defined as at least 15 days of headache in one month.
Secondary headaches are those caused by an underlying medical issue. Of children who are seen in the emergency department for headaches, the most common culprit is an acute febrile illness, like the common cold, the flu, or sinusitis. Typically, these headaches will go away when the illness resolves. Rare causes of secondary headaches occur when there is elevated pressure in the brain, which can be due to increased cerebrospinal fluid (CSF), a space occupying process (infections and brain tumors), pseudotumor cerebri, and low intracranial pressure (from leakage of CSF). Medication overuse headaches are due to excess use of medication to manage headaches. It is recommended that patients use medications such as ibuprofen or acetaminophen no more than three times per week to help prevent overuse headaches.
Children with uncorrected vision can experience headaches due to prolonged eye strain. After age 6, children with vision screens worse than 20/30 should be referred to an optometrist, who can conduct an evaluation to see if the child requires glasses. If it is recommended that your child wears glasses, make sure they do so regularly!
Other possible causes of recurrent headaches are listed below, and can be remembered with the mnemonic “SMART,” which was created by pediatric neurologist Dr. Heidi Blume:
- S is for sleep. Not enough sleep and too much sleep (or any disruption to a regular sleep schedule) can cause headaches. Children in school should get between 8-10 hours of sleep every night
- M is for meals and eating at least three full meals a day. As children get older and school starts earlier, many begin to skip breakfast. If there is no time for a sit-down breakfast, having a granola bar, a cup of yogurt or even some fruit on the go is better than nothing. Hydration is also important. A simple way to check hydration is to look at urine color: it should be clear.
- A is for activity, and believe it or not, too little or too much activity can lead to headaches, although typically it is the former that ails children. Children should be getting at least one hour of physical activity (outside of school regulated gym class) every day.
- R is for relaxation. High schoolers begin to experience an exponential amount of stress from schoolwork, peer pressure, and post-high school planning.
- T is for avoiding any known triggers, which can be specific foods, smells or environments.
Typically, the cause of headaches will not be found at the initial doctor’s visit. After a careful history and a thorough physical exam to exclude any causes of secondary headaches, children and families are encouraged to keep a headache diary. Entries should be as specific and descriptive as possible regarding each headache episode. The diary should then be brought to follow-up appointments, usually within 2-3 weeks of the initial examination. Between visits, patients are encouraged to use the “SMART” mnemonic to optimize their daily routines.