Director , New York Headache Center

The problem of headaches in children is often not taken seriously by both parents and pediatricians alike. While they may not be as prevalent as in adults (migraines occur in 6% in children as opposed to 12% in adults), headaches in children are quite frequent and deserve more attention than they have received. Many adult migraine sufferers report having attacks for as long as they can remember , and children as young as 2 have been known to suffer from headaches. The distribution of headaches between girls and boys is even until puberty when girls begin to outnumber boys. Among the reasons for a parent’s inattention to a child’s headache is reluctance to accept the child’s complaint as real or severe enough to warrant a visit to the doctor. Even if parents themselves suffer from headaches they are still doubtful, thinking that the child may be mimicking the parent’s complaint to get attention, or to avoid school or a household chores. Occasionally parents think that diagnosis of migraine will stigmatize their child and will interfere with a future career. Unfortunately, very often no medical attention is sought for a child with headaches. The active treatment of headaches in childhood is very important since it has been reported that chronic severe migraine headaches can sometimes cause permanent disabilities.

Diagnosis
Once the child is brought to a physician, he or she will usually make sure that no other serious condition is the cause of the headaches. Post-concussion, tension-type, and migraine headaches are by far the most common types in children as well as adults. Headaches during upper respiratory viral infections and other childhood diseases usually stop when the illness is over. Meningitis is a very serious condition which should be suspected in a child with a new onset of headaches and associated fever, neck stiffness and sometimes lethargy or confusion. Just like in adults, brain tumors and bleeding into the brain are not common causes of headaches. Seizures in children can occasionally manifest themselves only by headaches. Such presentation is even more unusual in adults. Emotional stress and overexertion are the two most common migraine precipitating factors in children. However, studies indicate that neither children nor adults with migraines are under more stress than people without migraines. Certain foods are well known to precipitate a migraine attack at any age. These include chocolate and sweets in general, dried, pickled, smoked, cured, and fermented foods. Skipping meals and dehydration can also bring on a headache. Lack of sleep or an irregular sleep schedule is a common trigger, particularly in teenagers. Sinus headaches are usually easy to diagnose – they are accompanied by a colored nasal discharge.

Treatment
The treatment of childhood headaches is very similar to that of adults. Dietary changes are more often difficult to implement in children. These include avoidance of hot dogs, pizza, chocolate and other foods mentioned above.

Biofeedback or another type of relaxation training is a very effective non-drug treatment for migraines in children. Long-term results of biofeedback treatment both in children and adults are very impressive- up to 80-90% of patients are still improved 5 years after the treatment. Children learn biofeedback technique very quickly. Many will stop having headaches after only 2 or 3 sessions. Children as young as 3 years of age can be trained to control their headaches using temperature feedback. Each session is 30-60 minutes long and the frequency of the treatment is 1-2 per week. The average number of sessions is 10 for adults and can be fewer for children. The treatment consists of learning, among other things, to increase the temperature of the body by watching it being constantly displayed on a computer screen. Relaxation training is part of the treatment process which must be done under the supervision of experienced staff. Meditation is a good alternative to biofeedback, which also has scientific support for its efficacy.

Magnesium deficiency is found in almost half of migraine sufferers, including children. The deficiency is often due to a genetic inability to absorb or retain magnesium despite normal intake of magnesium-rich foods. Magnesium supplements often help (magnesium glycinate, 400 mg to 800 mg is an adult dose), but a small number of patients require monthly intravenous infusions, which we perform daily at the New York Headache Center. Deficiency of CoQ10 is found in one third of children with migraines. Taking 100 mg to 300 mg daily can have a dramatic effect on child’s migraines. We also recommend several herbal supplements such as feverfew and boswellia, but not butterbur (see my blog post)

Many medications used to treat headaches in adults have not been tested for safety in children. Abortive treatment with triptans, such as sumatriptan (Imitrex, rizatriptan (Maxalt), zolmitriptan, (Zomig), and other is safe and effective in kids. Preventive drugs include beta blockers such as propranolol (Inderal), antidepressants, such as amitriptyline (Elavil), and epilepsy drugs, including gabapentin (Neurontin), divalproex sodium (Depakote), and topiramate (Topamax) can be effective in children. Botox is the most effective preventive therapy, which helps 70% of kids with chronic migraines and at the same time it is much safer than any drug. I’ve treated children as young as 8 with Botox with excellent results. Botox injections take less than 5 minutes to administer and they are not very painful (see these videos of me injecting two adult patients – here and here). The only downside of Botox is its cost, but most insurance cover it because it is an FDA-approved treatment for chronic migraines in adults.

In summary, headache in children is a serious but often underrated condition that often responds well to non-drug therapy, such as diet, biofeedback, magnesium and CoQ10 supplements and Botox.