Headache Medicine

Headache Medicine

Headache in Children

By: Ruby Castañeda-Regalado, MD

Last edited: December 5, 2025

Headache is a common complaint among children and adolescents and is the most common referral to neurology practices. While most headaches are harmless and go away within a few hours, recurrent headaches of any types can cause school problems, behavioral problems and/or depression.

Headaches can be classified as

Primary or Secondary type

Primary Headache

Headaches that are intrinsic to the brain. The headache itself is the disease process.
Examples would be migraine and tension type headache

Secondary Headache

Headaches caused by something else such as head trauma, brain tumors, infection, inflammatory diseases or increased intracranial pressure.

When to Call Your Child's Healthcare Provider for a Headache:

A headache consistently wakes your child from sleep
Your child experiences early morning vomiting
The headaches are worsening or occurring more often
Your child experiences personality changes
Your child complains that it is "the worst headache they've ever had"
The headache is different than previous headaches
The headache occurs with a fever or stiff neck
The headache happens after an injury
Your child is not headache-free after two doses of pain medication
Your child is frequently using medications for headaches
The headaches are causing your child to miss school or social activities
Your child is having more than three to four headaches per month

Does my child need to have a head scan?

A head scan is best reserved to evaluate a secondary type of headache.

Based from the guidelines of the American Academy of Neurology and the practice committee of the Child Neurology Society, obtaining a neuroimaging study on a routine basis is not indicated in children with headache with normal neurological exam.

Neuroimaging should be considered in children with an abnormal neurologic examination if there are symptom features that suggest recent onset of headache, change in the type of headache, neurologic dysfunction, and occipital location of headache.

Based on the available current literature, imaging should be considered for the following factors:

Headaches associated with gait abnormalities, seizures, weakness, double vision
Atypical presentation of the headache: vertigo, intractable vomiting upon awakening, or headache waking the child from sleep
Headache associated with systemic symptoms such as fever, stiffed neck, confusion, mental status changes, and increase in sleeping time
Headache of less than 1 month or started within the last 6 months
Subacute onset, change of headache type, progressive headache severity
New-onset headache in an immunocompromised child
First and or worst headache of her/his life
History suggestive of occipital headache
Age younger than 6-year-old complaining with headache
Absence of family history of migraine and/or primary headache

Primary Headaches

To improve the diagnosis of headache and to establish a standardized set of criteria to serve as a common basis for the additional scientific study of headaches, the (ICDH) International Classification of Headache Disorders was developed, and is now in its 3rd edition.

While there are hundreds of different causes and categories of headache, Primary headaches are grouped into 4 major categories - Migraine, Tension-type headache, Trigeminal autonomic cephalalgias and Other primary headache disorders.

Because a patient may receive more than one headache diagnosis at a time, it is important to track the specific symptom and trigger of the headaches.

The two most common cause of recurrent, primary episodic headaches in children are Migraine and Tension-Type Headache.

Migraine may be accompanied by an odd sensation called and aura. Auras can occur as visual (flashes of light), auditory (ringing in the ear), motor (weakness), sensory (tingling or numbness), brainstem (vertigo) or dysphasic (confusion) forms.

ICHD-3b Criteria for Migraine without Aura

Five recurrent episodes of headache over the last year lasting for 2-72 hours untreated
Throbbing pain, that is often on one side of the head, but can be on both sides particularly in children
Associated with nausea, vomiting, photophobia, phonophobia
Moderate to severe in intensity
Worsens with physical activity or limits physical activity

ICHD-3b Criteria for Migraine with Aura
Three headaches over the past year associated with aura
The aura should have 2 of the following 4 features:
- Lasting more than 5 minutes but less than 60 minutes
- Fully reversible
- Unilateral or one-sided
- The pain of the headache starts within 60 minutes (although it can be simultaneous, and the aura can occur during the pain of the headache)

ICHD-3b Criteria for Tension-type Headache

Other common form of primary headache in children
Recurrent headache of at least 10 episodes the past year
Headaches lasting 30 minutes to 7 days
Non-throbbing in character, diffuse in location
Mild to moderate in intensity
Not worsened or aggravated by physical activity

My child has been having headaches lately. What should I do?

If your child experiences recurrent headache, it is best to keep a Headache Diary.

Your Child Neurologist will use this diary to determine the best course of treatment for your child’s headache.

What to include in the Headache diary

Date and time of headache
Duration: How long the headache lasted?
Intensity/Severity: A scale of 1-10 to rate the pain
Location: Where the pain is felt
Symptoms along with the headache
- Nausea, vomiting
- Sensitive or avoids lights, sounds, or smells
- Dizziness or vertigo
- Aura or sensations before the headache starts (ex. flashes of light, weakness, tingling sensation or numbness)
Potential triggers/Lifestyle factors
- For women, hormonal factors such as menstrual cycle
- Hours of sleep
- Food or dietary and water intake
- Usual activities when headache begins
Management given: What helps relieve the pain?
Functional impairment:
- Impact on daily activity, did your child have to skip school or avoid certain activities?

Measuring headaches: mild, moderate or severe?

While any headache can certainly impact a child's day-to-day life, a useful tool that can help decide whether an intervention is effective or not is the Pediatric Migraine Disability Assessment (PedMIDAS). You can bring this up with your healthcare provider to help track your child's headache progress.

Some habits or lifestyle routines contribute to worsening of certain types of Primary Headaches. This is especially true for those predisposed to develop primary headache conditions.

Generally speaking, a healthy lifestyle starting with good nutrition, proper hydration, enough sleep and regular physical activity will help avoid health issues, including headaches. It will be useful to review these with your child and healthcare provider to identify areas where changes can be made to their day-to-day schedules.

Risk factors for primary headache

Family history and Genetic predisposition

Migraines tend to run in families. If one parent has migraines, there is roughly 50% chance that their child will too. If both parents have them, the chance is close to 90%.

Age and Gender

Before puberty, boys and girls have roughly the same incidence of migraines. After age 12, girls have more migraines, and by age 17, as many as 8% of boys and 23% of girls have had a migraine. For adults, migraines are more common in women due to hormonal changes.

Age and gender risk for tension-type headaches usually overlaps with migraine headache.

Cluster headaches, on the other hand tend to be more common in older age groups, rarely occurs in less than 10 years old and is more likely to occur in men than women.

Common lifestyle triggers that worsen Primary Headaches

Food and fluids

Skipping meals and eating certain foods and additives can set off migraines. Common triggers include aged cheeses and meats, chocolate, citrus fruits, red and yellow food dyes, monosodium glutamate(MSG) and the artificial sweetener aspartame. Too much caffeine and spicy foods can also trigger migraines, but sometimes help headaches because they act as vasodilators and expand blood vessels. Not drinking enough water and other beverages can cause dehydration, another migraine trigger.

Exercise

While exercise can sometimes trigger migraines, regular exercise may help prevent or reduce the number of attacks and attack intensity.

Stress and sleep

Irregular sleep schedules – getting too much or too little sleep – and poor sleep quality (such as frequent awakenings) can be migraine triggers. So are changes in stress levels.

My child's headache won't go away. What do I do?

Always make sure to check for headache RED FLAGS first.

These usually mean that it is a secondary headache and there is another condition causing the headache that may need further medical investigation and intervention.

If any of the headache RED FLAGS are present, it is best to urgently visit your doctor or trusted healthcare provider or to bring your child to an emergency room.

HEADACHE RED FLAGS

Persistent vomiting or vision changes
Sudden severe "worst-ever" headache
Headaches increasing in severity and frequency
Headache that wakes a child from sleep
Early morning headache with nausea
Headache with weakness, confucion, unusual sleepiness or seizure
Headache with fever, stiff nech or rach
Persistent headache in those with head trauma

Managing headaches will often include lifestyle changes to avoid triggers and medications for sudden attacks of headache.

The initial medication prescribed for headache attacks will commonly be analgesics such as acetaminophen or paracetamol, or products that combine Acetaminophen, Aspirin and Caffeine, and nonsteroidal anti-inflammatory medicines such as Ibuprofen and Naproxen. Triptans may be prescribed specificlly for those with migraine type headaches.

Keep in mind that medication overuse headache may start if these are used more than 3 days a week, or 10-15 days a month.

If your child continues to have headache attacks despite lifestyle changes and taking these medications, it is best to consult with your Child Neurologist or a Headache Specialist for further evaluation.

Resources:

Swaiman’s textbook of Pediatric Neurology 6th Edition
American Academy of Pediatrics, HealthyChildren.Org
https://www.healthychildren.org/English/Pages/default.aspx
Cincinnati Children’s Hospital Headache Center Resources
https://www.cincinnatichildrens.org/health/h/headaches