Chronic daily headache
Migraine headache
Migraine headache with aura
Migraine headache without aura
New daily persistent headache
Tension headache

The first step when evaluating children and adolescents with headaches is to rule out secondary headaches, those headaches caused by underlying conditions. Red flags in headache diagnosis include: the worst headache of your life, worsening frequency or intensity, headache accompanied by changes in the neurologic exam, headaches that are always on the same side/same location, headache with symptoms of infection, headaches that are worst at the time of onset, headaches that are worse with standing or sitting, and nocturnal or early morning headaches. Headaches that come and go with a full return to baseline are generally primary headaches and do not require further testing.

Ask about the pattern of the headaches, frequency, intensity, associated symptoms, factors that trigger the headaches, anxiety, depression, and school performance. Motion sickness, including car sickness, is more common in individuals with migraine than in the general population. [Murdin: 2015]

A family history of migraine-like headaches, particularly in female relatives, is common. You may have to probe a little for this history because families may not see it as connected to the patient being seen. For instance, the mother may say that she had headaches when she was an adolescent or only gets headaches with her periods.

The goal of the physical exam is to rule out identifiable and/or treatable causes of the headaches. Other than demonstrating pain or distress if a headache is present, the child should appear normal. Check vital signs for increased blood pressure. The neurologic exam should be normal. An abnormal funduscopic examination or sixth nerve palsy suggests possible pseudotumor cerebri syndrome. If not comfortable with the fundoscopic exam, a referral to ophthalmology for a dilated exam is always appropriate. Many normal variations look abnormal but are within the normal range and ophthalmology can help sort that out. Rarely, refractive errors (astigmatism or far-sightedness) may contribute to headaches and, if suspected, the child should be referred to optometry or ophthalmology. [Gil-Gouveia: 2002]

After secondary headaches are ruled out, it is important to classify the type of primary headache being experienced by the child. Possibilities include migraine with or without aura, tension headaches, chronic daily headaches, etc.

Although some evidence suggests that these reflect a spectrum of the same condition, they are generally defined as:

Trigeminal autonomic cephalgias are another headache category that includes primary stabbing and cluster headaches, entities seen much less commonly in children than in adults.

The International Headache Classification (ICHD-2) for pediatric migraine can guide the medical home clinician in diagnosing and managing children with migraine headaches without specialty referral. [Ozge: 2011] If headaches are unresponsive to treatment, become more frequent or severe, or are associated with a concerning history or exam findings, collaboration with Pediatric Neurology (see NW providers [0]) may be helpful.

This may involve a single consultation resulting in recommendations and a treatment plan. Occasionally, ongoing neurology management and/or other subspecialty involvement may be indicated. Many neurologists’ considerations can be addressed by the medical home before referral, including sleep hygiene, hydration, regular/healthy meals, use of electronics, and psychosocial factors in the home or school, such as divorce or bullying. Some children/adolescents may benefit from Behavioral Health referral for stress reduction techniques, school or family problems, anxiety.

Features of migraines in children may include:

• Frontal and bilateral localization in children - more likely unilateral in adolescents and adults
• Preceding aura (~33% in children and adolescents) – because children and parents often don’t recognize aura, it should be asked about specifically
• Nausea and vomiting
• Throbbing quality of pain
• Sensitivity to light and/or sound; may be inferred from behavior
• Improvement with sleep
• Duration as short as 1 hour

Childhood periodic syndromes that may represent migraine variants include:

• Cyclic vomiting
• Abdominal migraine
• Benign paroxysmal vertigo of childhood
• Benign paroxysmal torticollis of infancy
• Colic [Gelfand: 2012]

Chronic daily headache is defined as:

• Headache present 15 or more days per month AND
• Present for 3 or more months [Hershey: 2006]

Chronic daily headaches can be the first presentation of headache (e.g., new persistent daily headache, often triggered by an illness or infection). It may also evolve (“transform”) from less frequent migraine or tension headaches. Chronic daily headaches likely result from physiologic changes in response to environmental stresses, a propensity to headaches, and sometimes a trigger such as an illness. Known risk factors are obesity, sleep disorders, anxiety, depression, female gender, and age. [Lipton: 2011]

Frequent pain with the appropriate stressors initiates a feedback loop leading to sensitization of central nervous system pain pathways. [Mathew: 2011] Although the physiology of this loop is understood, the cycle is very difficult to interrupt and management will usually require multiple modalities. It is important to assure families that no underlying condition is causing their child's headache and explain that pain relief will not be immediate. Realistic expectations for pain relief and understanding the importance of lifestyle changes for the child/adolescent and family are critical for success.

Since children often do not have the characteristics of migraine headaches found in adults, the diagnostic criteria are different and less strict for them. The following criteria are from the International Headache Classification (ICHD-2) [Headache: 2004]:

Migraine without aura

A. At least 5 attacks fulfilling criteria B–D

B. Headache lasting between 1–72 hours (untreated or unsuccessfully treated)

C. Headache that has at least 2 of the following characteristics:

D. During headache, at least 1 of the following:

E. Not attributed to another disorder

Migraine with aura

A. In addition to the criteria for migraine without aura, at least 2 attacks fulfilling at least 3 of the following:

Hemiplegic migraine

This is a rare type of headache, now considered a subtype of migraine with aura, and is essentially a diagnosis of exclusion of other causes of focal weakness, particularly stroke. Hemiplegic migraine has been linked to 3 different gene mutations and occurs in familial and sporadic forms.

Laboratory Testing

Labs for thyroid function, CBC with differential, a complete metabolic profile, erythrocyte sedimentation rate, iron studies, Vitamin D, and coenzyme Q10 may be ordered in children whose headaches occur daily or almost daily. No evidence suggests a standard lab panel for patients with classic migraine symptoms.

Imaging

Imaging is not usually needed to investigate or diagnose primary headaches, although it may sometimes be useful in ruling out underlying causes. Imaging is recommended if a child has an abnormal neurological exam or if the child has had headaches for fewer than 6 months with an increasing trajectory of severity and no family history of migraine. If brain imaging is to be performed, MRI is the preferred modality. [Trofimova: 2020] [Prpić: 2014] [Sarma: 2019]

Genetic studies clearly show that primary headaches (including migraine, tension, and cluster headaches) are multifactorial disorders characterized by a complex interaction between different genes and environmental factors. [Anttila: 2018]

Chronic daily headaches are thought to occur in about 1% of children and adolescents. [Lipton: 2011] Age-specific prevalence of migraines are: 3-7 years old (1-3%), 7-11 years old (4-11%), and 11-15 years old and older (8-23%). [Lewis: 2002] In childhood, headaches affect girls and boys about equally; in adolescence, girls have more headaches than boys. [Abu-Arafeh: 2010] Migraine and tension headaches are responsible for 91% of chronic pain in children. [Zernikow: 2012]

Although considerable literature describes the differences between migraine and tension headaches, many experts believe that migraines, tension headaches, and chronic daily headaches represent a continuous spectrum of pain caused by similar mechanisms.
Hemiplegic migraine involves 1 or more limbs that are numb, weak and/or do not work well. A child with numbness may have difficulty walking. Headaches with aura and numbness or paresthesias may be difficult to separate from hemiplegic migraine; distinguishing between the 2 is important.
New daily persistent headache is a type of chronic daily headache that starts suddenly; usually, stress, illness, or surgery triggers it. Although the diagnosis is usually one of exclusion, the sudden onset can be worrisome to families and providers, so it is helpful for clinicians to know about this headache subtype. [Evans: 2012]

In children with a long history of headaches, no chronic medical diagnoses (e.g., tuberous sclerosis or shunt-dependent hydrocephalus), no unusual historical findings (e.g., personality changes or seizures), and normal neurologic exams, the headaches are almost always primary headaches.
Tumor or subarachnoid hemorrhage and other underlying etiologies may be a consideration in children who have an acute progressive course of headaches, the “worst headache of their lives,” accompanying symptoms such as personality changes or seizures, or an abnormal neurologic exam.
Pseudotumor cerebri syndrome (previously called idiopathic intracranial hypertension) can be primary or secondary. [Friedman: 2013] In this condition, elevated cerebrospinal fluid pressure causes headaches and, if not treated, can lead to visual loss. This cause of headache is more common in obese adolescent girls, particularly if they are on hormonal therapy or certain acne treatments (e.g., minocycline, retinoic acid). Diagnostic criteria depend upon funduscopic evaluation, cranial nerve findings, neuroimaging studies, and/or performance of lumbar puncture for measurement of opening pressure.
Chronic dehydration is likely to contribute to headache perpetuation.
Obesity and hypertension are associated with increased headache frequency and disability. [Hershey: 2009]

Screening For Complications

Consider screening children and adolescents with headache for anxiety, depression, school difficulties, and bullying. [Blaauw: 2015] Screening tools and management info can be found in the Portal’s module on Depression. Catastrophization of pain by either the youth/adolescent or the parents may worsen headache; the Pain Catastrophizing Scale (PCS) may be helpful to identify this. [Parkerson: 2013]

Track interim frequency and intensity of the headaches; increasing number or intensity likely signals a need to change the care plan. Determine precipitating events and/or triggers, duration, frequency, character of headaches, and if oral contraceptive pills or antibiotics (e.g., for acne) are used.

Ask about:

• How often the child/adolescent is taking pain medication of any kind, including acetaminophen, ibuprofen, etc., as frequent medication use may result in medication overuse syndrome. Ask about the child/adolescent’s headache plan – what medications do they take for headache relief and when.
• Depression, anxiety, social problems such as bullying, school difficulties, all of which may be impacting headaches.
• Whether the headaches are causing frequent school absences and if so, consider a referral to Behavioral Health. The social and academic burdens for children who are missing school due to headaches are immense. Parents can also experience significant emotional burden and economic stress if they are missing work to care for their child.
• Family and social stressors that may be contributing to the cycle of headaches and missed school days. Though some families keep their child home from school because of headaches, this can be isolating and return to school should be encouraged.

There are 3 major categories of headache treatment.

• The first and most important involves working with the child/adolescent to follow a healthy lifestyle and avoid triggers for the headaches. Stress is the most common trigger. [Neut: 2012]
• Second, treat acute, intermittent migraine headaches with medication. If ibuprofen/Tylenol are not successful, there are specific migraine medications that should be prescribed. If necessary, anti-nausea medications should also be prescribed, as well as a medication to help the child with a severe headache get to sleep.
• Third, preventive medication may be helpful in some children/adolescents, including daily oral and or botulinum toxin injections.

1) Lifestyle Modifications/Trigger Avoidance

Headache prevention includes:

• Adequate hydration: It might be helpful for individuals with headache to follow a regimen such as a glass of water an hour while awake. Children and adolescents can assess their hydration status by looking at the color of their urine. Adequate hydration is suggested by clear or light-yellow urine.
• Constant blood sugar levels: Eat small, frequent meals with a low glycemic index - to avoid quickly rising and falling blood sugar during the day. Avoid skipping meals.
• Weight reduction: In individuals who are obese, losing weight leads to a decreased headache frequency. [Hershey: 2009] [Robinshaw: 1996]
• Exercise: Children and youth aged 5-17 should accumulate at least 60 minutes of moderate to vigorous intensity physical activity daily (see Global Recommendations on Physical Activity for Health: 5–17 years old (WHO)).
• Sleep: Children 6-12 should sleep 9-12 hours a night; adolescents 13-18 should sleep 8 to 10 hours a night.
• Stress and anxiety: These common problems interfere in headache treatment and should be actively asked about and treated with behavioral interventions if necessary (see Anxiety and Depression in Children (CDC)).

Gather more information about headaches. Having the child keep a headache diary with precipitating/alleviating factors, dates of menstrual periods if a female, and medication overuse may be helpful. Numerous apps and charts can be found online. Examples of headache journals:

• Headache Log (Our Family Doctors) ( 28 KB); Printable record with areas to note time of onset, activity prior to headache, location of headache, duration, pain scale, medication taken and its effectiveness, triggers, and associated symptoms.
• Headache Diary (National Headache Foundation): Simple, printable headache recording form with instructions on its use.
• iPhone and Android apps also can serve as headache journals.

Recognize triggers for headache and prevent exposure to environmental triggers may be helpful. Examples of environmental triggers include school starting again, additional AP classes, a move or divorce in the family. Children who have a lot of stress or anxiety may benefit from behavioral health techniques such as distraction/relaxation and cognitive-behavioral therapy.

Although more frequently observed in adults than children/adolescents, ask about foods that may trigger headaches. Common food triggers include strong cheeses, caffeine and alcohol, foods with MSG, nuts, high-carbohydrate meals, sugar, chocolate, pizza, shellfish, and processed meats (bacon, hot dogs, pepperoni).

Behavioral Health In children/adolescents with frequent headaches, behavioral health techniques (distraction/relaxation techniques and cognitive behavioral therapy) can help reduce headache frequency and severity.

2) Acute Medications

Treatment

• Appropriate pain control (while avoiding overuse of NSAID medications or narcotic exposure)
• Anti-nausea medications, a low-stimulation environment (no light, reading, or electronics)
• Promotion of sleep

Guidelines

• Oskoui M, Pringsheim T, Holler-Managan Y, Potrebic S, Billinghurst L, Gloss D, Hershey AD, Licking N, Sowell M, Victorio MC, Gersz EM, Leininger E, Zanitsch H, Yonker M, Mack K.
  Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.
  Neurology. 2019;93(11):487-499. PubMed abstract

Acute medications target pain or attempt to abort onset of pending headache, and they should be used as close to the start of the headache as possible. Families should know that using these medications more than 2 to 3 times a week might cause medication rebound headaches that can be difficult to differentiate from chronic daily headache.

• Non-steroidal anti-inflammatory drugs (e.g., aspirin, ibuprofen, and naproxen sodium): Except for acetaminophen, each of these is best taken with food, which may be difficult for adolescents who skip meals or feel nauseous. Naproxen sodium (Aleve) liquid or caplets may work faster than other preparations.
• Triptans (serotonin receptor agonists) are often very effective but expensive and may not be covered by insurance. [Eiland: 2010] Options include sumatriptan (Imitrex), almotriptan (Axert), rizatriptan (Maxalt).
• New preparations that contain naproxen and sumatriptan may be especially helpful. Treximet is the first medication with this combination approved for the acute treatment of migraine with or without aura in pediatric patients 12 years old and older.
• Caffeine, taken along with any of the above, is sometimes helpful. Possible ways to get caffeine include Excedrin, soda, or even espresso shots.
• Antiemetics/Sleep inducers may also be needed. Options include promethazine, prochlorperazine, and ondansetron. Promethazine, metoclopramide, and prochlorperazine may also have some direct effects on migraine. Pretreatment with diphenhydramine or hydroxyzine 15 minutes or so before the antiemetic can prevent dystonic reactions sometimes associated with these medications. Ibuprofen and an antiemetic can help the child sleep and are effective and safe options for children younger than 12 years old.

Occasionally, children and adolescents with debilitating daily headaches that have not responded to other therapies are treated in the emergency department. The Pediatric Emergency Department Patient with Headache (Primary Children’s Hospital) ( 102 KB) is one example of intravenous treatment for children/adolescents with severe migraine that does not include narcotics.

3) Preventive Medications
Preventive medications have been recommended when headaches occur more than 3 days per month [Winner: 2008]; however, a randomized, double-blind study of children and adolescents found that these medications are not helpful. [Powers: 2017] [Powers: 2017] The same headache center that ran the study (the University of Cincinnati Headache Group) strongly supports the use of cognitive-behavioral therapy in headache management. [Kroner: 2017] [Amos: 2014]
The only exception to the lack of efficacy for medications in preventing headaches may be the new calcitonin gene-related protein (CGRP) inhibitors, which are monthly injections or quarterly IV infusions (depending on particular formulation) for either frequent episodic migraines or chronic daily headaches. These have not yet been tested in the pediatric population and cost $6000 to $7000 per year.
Guidelines If preventive treatment is deemed worth trying are:

• Oskoui M, Pringsheim T, Billinghurst L, Potrebic S, Gersz EM, Gloss D, Holler-Managan Y, Leininger E, Licking N, Mack K, Powers SW, Sowell M, Cristina Victorio M, Yonker M, Zanitsch H, Hershey AD.
  Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.
  Headache. 2019;59(8):1144-1157. PubMed abstract

It is important to continue behavioral therapies and lifestyle modifications even if preventive medication is being trialed. Trial and error dosing is required because efficacy and side effects are difficult to predict; timely feedback on response is needed to guide dose adjustments. Their use in children is off-label—check all dosing and safety information before prescribing. Start with a medication suited to the age and weight of the child and likely to cause few or very tolerable side effects, then increase the dose slowly at 1- or 2-week intervals. ("Start low and go slow.") A common approach is to start with cyproheptadine in children up to 10 years of age, topiramate in adolescents or in children over 10 who are overweight, and amitriptyline in adolescents with normal weight, low weight, or comorbid depression/anxiety and/or difficulty falling asleep.

An adequate trial of a single preventive medication takes 6-8 weeks. If not successful, it can be tapered quickly (to 1/2 the current dose for 3 days), stopped, and another one started. The goal, which should be discussed before initiating treatment, is to decrease headaches to a manageable frequency (for example, <2 a month). After this frequency has been achieved, continue the medication for 3-6 months before considering weaning. Some experts suggest treating for an entire school year to re-establish a pattern and expectation for attendance and performance. Wean by reducing the dose by about 1/4 at weekly intervals. If headaches return, increase to the effective dose for longer than the initial treatment before weaning again. Behavioral therapies and lifestyle changes should be continued indefinitely.
A 31-injection protocol for Botulinum toxin (Botox) injections has been approved for individuals 18 years of age and older for chronic daily headache; it is the only treatment approved for chronic daily headache. While not FDA-approved for use in children, 1 study showed a statistical improvement in headache frequency in children. [Kabbouche: 2012]

• Onset and duration of benefit varies widely with repeat injections generally required every 3 to 4 months
• Side effects may include headache exacerbation, pain at injection site, and facial paresis
• Many insurance companies require failure with 3 preventive medications before approving Botox injections, including one antiepileptic, usually topiramate, one anti-depressant, usually amitriptyline, and one “heart drug,” usually propranolol, despite the lack of evidence for their efficacy.

Consider screening children and adolescents with headache for anxiety, depression, school difficulties, and bullying. [Blaauw: 2015] Screening tools and management info can be found in the Portal’s Depression. Catastrophization of pain by either the youth/adolescent or the parents may worsen headache; the Pain Catastrophizing Scale (PCS) may be helpful to identify this. [Parkerson: 2013]

Children/adolescents with migraine may have significant stress/anxiety that should be addressed either by the provider or a referral to Developmental - Behavioral Pediatrics (see NW providers [1]). Lifestyle modifications are very helpful in decreasing frequency of migraines. Children with chronic daily headache often have frequent school absences, mood disorders, and sleep problems that contribute to headaches. By the time headaches have become chronic, treatment involves chipping away at contributing things.

Managing stress includes:

• Mitigation of environmental factors, such as artificial light or loud noises
• Relaxation training, behavior modification, hypnosis, meditation, biofeedback, acupuncture, and similar interventions: An audio or visual stress relaxation guide for the child and parent may be helpful, although consistent use is a challenge. Yoga classes in community centers are fairly inexpensive and sometimes geared toward children. Although it is possible that a child/family can do this on their own, sometimes a coach from Behavioral Health in the form of cognitive-behavioral therapy may be helpful. See Referral to Behavioral Health for Chronic Pain Management (Primary Children's Hospital) ( 260 KB).
• Many children with frequent headaches are perfectionists and need to be taught pacing of activities. Cognitive-behavioral therapy with a behavioral health professional may be helpful. This is not counseling in the traditional sense but practical behavioral tools.
• Regular exercise, for example walking 45 minutes 5–7 times/week [Krøll: 2018]
• Adequate sleep, especially for adolescents who often start school before 8 a.m. This should be actual sleep and not just time spent in bed with an electronic device.
• If extra-curricular activities are becoming too stressful, causing fatigue, or preventing lifestyle modifications that can prevent headache, families might want to rethink participation.

Often a letter to the patient’s school requesting 504 Plan accommodations is useful. Accommodations may include the ability to use a water bottle and the bathroom when necessary or decreased homework (e.g., shorter essays or every other math problem), so the amount of missed work due to absence for headache does not feel insurmountable. The child or adolescent, and their family, will likely have ideas for accommodations that they think will be useful. If the child has already missed a lot of school, communication with the teacher and support from a Behavioral Health specialist will be especially important. In general, the child should not be withdrawn from school because of headaches. Education & Schools provides further information about communications, supports, and eligibility for 504 accommodations. See Referral to Behavioral Health for Chronic Pain Management (Primary Children's Hospital) ( 260 KB).

Because medications are more likely to control pain if taken at the beginning of a headache, affected children and adolescents should have medication available at school. The medical home provider often will need to fill out a school form to allow the administration of medication at school. Transitioning a child to online or home-school because of headache can be isolating. Maintenance of a regular school/work/play routine is encouraged for promotion of health and to avoid long-term social, academic, and work-related consequences.

All children with migraine or chronic daily headache should have a written headache management plan to inform and guide care in case they get a headache at school or experience a headache that leads to an emergency department visit.