Headaches

Headaches in children are generally divided into two categories: Primary headaches and secondary headaches. Primary headaches occur on their own and are not a symptom of something else; secondary headaches are caused by a medical condition.

Types of primary headaches include:

• Migraines involve severe pain, nausea, vomiting, and sensitivity to light or sound. Some children also experience visual disturbances or auras before a migraine starts.
• Tension-type headaches often feel like a band tightening around a child’s head. They are usually associated with stress or muscle tension.
• Cluster headaches occur in cyclical patterns or “clusters” and cause intense, sharp pain behind or around one eye or one side of a child’s head; they can be accompanied by redness or tearing of the eye.

Types of secondary headaches include headaches due to:

• Trauma
• Infection
• Vascular conditions such as moyamoya disease, brain aneurysm, and arteriovenous malformation (AVM)
• Psychiatric factors such as depression, anxiety, and stress
• Structural abnormalities of the head and skull, such as craniosynostosis, cleft palate, and strabismus
• Sinus headaches caused by inflamed sinuses, which lead to pain in the forehead, cheeks, or around the eyes.
• Medication-overuse headaches as a result of overusing pain medication. They can become more frequent and severe as the body becomes dependent on the drug. They typically occur when a medication is used more than two or three times a week.

Chronic daily headaches

Chronic daily headaches are migraines and tension-type headaches that have been present for more than three months. They can be triggered by an infection, minor head injury, or overuse of pain medications. Boston Children’s Hospital treats chronic headaches in our Chronic Headache Program in Pain Medicine.

At Boston Children’s, our experienced Neurology Headache Program team works with you and your child to identify the causes of their headaches and coordinate comprehensive care.

To determine the type and cause of your child’s headaches and the most appropriate treatment, our team will:

• Review your child’s medical history
• Discuss symptoms with you and your child
• Perform a physical and neurological exam
• Order additional tests if needed, such as blood tests or brain imaging. If your child’s headaches are classified as “primary” (e.g., migraines, tension, or cluster headaches) and a neurological exam is normal, further testing might not be necessary.

Common questions we might ask include:

• When do the headaches occur?
• Where is the pain located?
• How does the pain feel and how long does it last?
• Do headaches impact daily life and how?
• Are there any additional symptoms?
• What treatments or medications have been tried?
• Is there anything that triggers the headaches?
• Is there a family history of headaches?
• Is there a history of stress, anxiety, or other medical conditions?

Headache pain is generally the result of muscle tension, expanded blood vessels in the head, and temporary changes in brain chemistry. Many things can cause headaches in children and young adults, including not drinking enough fluids, skipping meals, weather changes, stress, and irregular sleep schedules.

At Boston Children’s, our experienced Neurology Headache Program team works with you and your child to identify the causes of their headaches and coordinate comprehensive care.

To determine the type and cause of your child’s headaches and the most appropriate treatment, our team will:

• Review your child’s medical history
• Discuss symptoms with you and your child
• Perform a physical and neurological exam
• Order additional tests if needed, such as blood tests or brain imaging. If your child’s headaches are classified as “primary” (e.g., migraines, tension, or cluster headaches) and a neurological exam is normal, further testing might not be necessary.

Common questions we might ask include:

• When do the headaches occur?
• Where is the pain located?
• How does the pain feel and how long does it last?
• Do headaches impact daily life and how?
• Are there any additional symptoms?
• What treatments or medications have been tried?
• Is there anything that triggers the headaches?
• Is there a family history of headaches?
• Is there a history of stress, anxiety, or other medical conditions?

Treating headaches in children involves an individualized approach based on the type and severity of the headache, along with the child’s overall health and needs. Treatment plans may involve:

Lifestyle and behavioral changes

• Lifestyle changes such as establishing regular sleep patterns, proper hydration, and  balanced meals
• Stress management techniques like relaxation exercises or mindfulness.

Medications

• Over-the-counter medications such as acetaminophen or ibuprofen for mild headaches
• Prescription Medication for more severe or chronic headaches

Therapies

• Cognitive behavioral therapy (CBT) can help manage headache-related stress and anxiety
• Biofeedback teaches techniques on how to control physiological functions to reduce pain
• Physical therapy to address muscle tension or postural issues

Alternative treatments

• Acupuncture
• Dietary changes

The long-term outlook for children with headaches varies depending on the type of headache, its severity, its cause, and the effectiveness of treatment. Most children with headaches can lead healthy, active lives with proper treatment.

A comprehensive treatment plan can help children who experience migraines or tension-type headaches see a reduction in pain frequency and intensity. This plan may involve lifestyle changes, vitamin supplementation, medications for immediate headache relief and frequency reduction, and complementary treatments such as cognitive behavioral therapy or biofeedback therapy.

Children with chronic headaches may require ongoing treatment, but early and effective care can reduce the frequency of their headaches and improve their quality of life. Headaches that are linked to other conditions, such as sinus infections or head injuries, usually improve once the primary concern is treated.

We specialize in diagnosing and treating headaches in children and young adults through a comprehensive approach. Our services include personalized care and recommendations, coordination with your child’s primary care provider, access to our multidisciplinary clinic located in Waltham, as well as care in Boston, Lexington, Peabody, and Weymouth.

Our multidisciplinary team includes:

• Child neurologists
• Pain management specialists
• Psychologists
• Complementary care providers

Children with headaches are initially evaluated in our Neurology Headache Program. We may refer chronic or complex cases to our Chronic Headache Program in Pain Medicine.

Since a patient may receive headache care from her pediatrician or with a neurologist, coordinating care can be a challenge. Neurologists at Boston Children’s Hospital work to develop effective plans of care for our patients and families and partner with primary care physicians so that together we can provide the best care possible.

In order to make this collaboration even more effective, neurologists from Boston Children’s and primary care physicians from Harvard Vanguard Medical Associates (HVMA) have come together to develop new ways of working together. Our new approach allows children to receive a larger portion of their ongoing headache care from their pediatricians, strengthening their connection with their primary care providers and providing for more comprehensive, well-coordinated care. This approach should also shorten wait times for appointments in our neurology department and lower medical costs for families. Together with our partners at HVMA, we aim to deliver family centered care to our patients in the most appropriate setting.

We look forward to expanding this collaborative model to include other primary care provider groups, as well. We know that when we work closely with primary care doctors, it benefits our patients.

There is a lot still to be learned about children’s headaches. So headache specialists at Boston Children’s are engaged in research to learn more about how headaches happen, their effects and how to best treat them.

Boston Children’s neurologist and pain management specialist Alyssa LeBel, MD, and her colleagues are using a type of brain scan called functional magnetic resonance imaging (fMRI) to study how the brain activity of children and teens with migraines is different from the brain activity of kids who don’t have migraines. This information may lead to a better understanding of migraines — and, we hope, better treatments for them.

Boston Children’s physicians and psychologists are also studying how effective non-drug therapies, such as biofeedback, are for children with chronic headaches including migraines. Research like this can help to improve treatment protocols for children with headaches — both at Boston Children’s and at other institutions.

We value our interactions with our patients' primary care providers and are eager to make coordination and reporting of care as productive as possible.

In 2009, a group of specialists from Boston Children's Hospital, including Scott L. Pomeroy, MD, PhD, neurologist-in-chief, and Richard C. Antonelli, MD, MS, medical director for integrated care, sat down with primary care providers from Harvard Vanguard to develop strategies of collaboration for the care of our patients. Drawing on feedback from patient families, we designed new, coordinated systems for PCPs and sub-specialists to work together.

• Our neurologists provide information and support to primary care physicians assessing their patients for headaches. As needed, neurologists provide guidance to primary care doctors to ensure their patients see a neurologist for further evaluation when necessary and help determine what imaging might be most appropriate for individual patients on a case-by-case basis.
• Whenever a child is seen in the Department of Neurology, we quickly report our findings and recommendations back to the referring provider so she can continue to coordinate care for her patients.
• We support ongoing communication between neurologists and primary care providers, strengthening connections with pediatricians and providing for more comprehensive and convenient coordination of care.

We look forward to expanding this collaborative model to include other primary care provider groups, as well.