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Pediatric Headaches

Initial treatment of pediatric headaches may benefit by using conservative, reversible modalities for tension headache before resorting to medications for migraine.
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Patient J was only four when she began a three-year battle with headaches. Her headaches affected her ability to sleep, eat, focus, participate in sports, interact socially and enjoy life. Her mother, a physical therapist, was terrified. “It was awful. I see children every day who are suffering from brain tumors, head trauma, and other serious pathologies of the head. What if my child had something like that? It is hard for a mom not to worry. She was in so much pain. I was really scared.”

For several years her quest for answers was futile. She consulted her daughter’s doctor, a neurologist, and a pain specialist. Patient J was subjected to blood tests, brain scans, sinus imaging, and nearly every test imaginable. Most of the doctors prescribed pill after pill hoping one would work. “The buck was always being passed. I had a fist-full of prescriptions: allergy pills, sedatives, anti-seizure medications, opioids, anxiety medications—you name it. Everyone kept giving me Band-Aid solutions without determining the cause. As a mother, I was not excited about the prospects of a sedated headache free child or a child that would always be in pain.”

As children grow from preschool age to school age, there is a marked increase in the number of headaches experienced. In 1974, the prevalence of pediatric head-aches among 7-year-olds was only 14%. By 1992, this number had increased to an alarming rate of 50%. This is especially worrisome when we consider that the pediatric headache is the earliest sign of a life-long predisposition for headaches.1

Doctors empathetically care for patients and want the best for them, yet pediatric headaches are very difficult to diagnose and treat. For both the doctor and the parents, the desire is to reduce the pain and suffering of the child with treatment which does not impair the child. This is double jeopardy for a loving parent.

The most common misconception is that a severe headache must be a migraine. This leads to the thinking that the only tools available to treat severe headaches are migraine medications which may have multiple adverse side effects, including the possibility of impaired processing and communication. Analyzing the gamut from medical school to neurology residencies and courses taught through the American Headache Society, the primary focus is the migraine headache and its treatment. When diagnostic tests and drugs fail to reduce the headache pain and/or the headaches become a chronic daily intrusion, parents have nowhere to turn, nowhere to go for help, and no answers. The only thing that is worse than chronic pain is no hope of relief. Fortunately for this mother, a moment of prayer led her to seek out a long shot—her family dentist—even though she had little hope of an answer from a dentist about headaches. He indicated that he could not treat the problem, but he knew of a specialist who treated tension headaches in children. What was even more exciting was that the treatment did not involve the long term use of drugs. He referred Patient J to Raleigh Facial Pain Services (RFPS). Within three weeks of her initial exam, Patient J’s headaches were almost a thing of past. Within two months of active care, she was pain free. As an added bonus, she did not have to depend on mind-altering drugs for the rest of her life. There is no better gift to give a parent or a child than a way to remove a child’s pain which had previously appeared hopeless.

Diagnostic Issues

The scant literature available is written from a “migraine perspective” that gives very little insight into the reality of tension headaches. Research laws are quite restrictive thus making it difficult to conduct adequate research to properly evaluate diagnostic and treatment modalities. Typically, pathologies that have a simple basis for pain are more easily investigated and treated. However, the multifaceted nature of the pediatric headache contributes to the complexity of the diagnosis issue. Most experiments, by design, look at only one variable, and so typically render the studies to date uninformative as to the cause of the pediatric headache. When the multifaceted nature of pediatric headaches came to be understood, it explained why doctors were so frustrated with the lack of help from the sciences. While science provides diagnosticians with additional tools, knowledge, and facts, practice is still an art that cannot be placed into a straightforward “fix it” box. Research is forthcoming, but it is slow.

Because of this relatively scant scientific research, there is difficulty in accurately diagnosing of headaches that have overlapping symptoms. For instance, the IHS Criteria List used in migraine diagnosis includes many of the symptoms that are also associated with tension headache. Further, there are many migraine variants in addition to the “common” and “classic” migraines. A child could have severe tension headaches and moderate migraines, rendering the current standard diagnostic criteria invalid. There is even one headache variant that can only be diagnosed by its reaction to a specific medication.

It can be quite difficult for a child to describe the pain they feel and it takes a lot of effort to communicate on a child’s level.2 Most children do not have enough life experience to be able to adequately convey the symptoms they are experiencing. Even adults have difficulty describing feelings and symptoms of pain. Language and cultural barriers also impair communication of symptoms.

Bruxism has long been associated with pediatric headaches.3 Unfortunately, nearly 90% of the population are unaware of this bad habit. The nocturnal biting force is at least six times greater than during the day.4 Grinding is easier for the parent to perceive because of its audible nature.

A child experiencing severely painful, undiagnosed headaches tends to create a fear of cancer in parents. It is easy to understand this type of parental fear. They may even become frustrated with the doctor because there may have been three or more drug failures and no answers. The undiagnosed headache sets the stage for unfounded fear, unnecessary tests for the child, and creates a possible waste of medical dollars.

Types of Headaches

According to currently available literature, nearly 50% of pediatric headaches are tension headaches5 but the author suspects that this percentage is significantly higher. While a few children do suffer from migraines, pediatric studies are somewhat limited and most professionals rely on adult statistics when discussing the pediatric population.

In adults:

  • 48% of females—tension headache6
  • 38% of males—tension headache6
  • 18% of females—migraines7
  • 8% of males—migraines7

The few pediatric studies available indicate that 5.3% of 15 year olds have migraines, with 60% of them being male. The numbers for tension headache are obscure due to poor definitions, the many restrictions on studies, and the multifaceted nature of headaches.

Last updated on: November 18, 2013
First published on: November 1, 2006