By David I. Sandberg, M.D. FAANS, FACS, FAAP
Pounding, splitting, throbbing, nagging, crippling, caught in a vise, jabbed with a red-hot poker—these are words people use to describe headaches. Having one is bad enough, but watching someone else suffer is just as bad, especially if it’s your child. At some point, we might wonder, “When is a headache more than a headache?”
The tricky thing about headaches is two-fold. First, they are extremely common. According to the American Academy of Pediatrics, frequent headaches are among the top three reasons parents seek an office visit for their child, right up there with abdominal pain and chest pain. Approximately 75 percent of teenagers report having a headache at least once a month.
Second, headaches are caused by a lengthy list of triggers: lack of sleep; overexertion; dehydration; stress at home or school; excessive “screen time” via television, Internet and video games; vision problems; allergies; and even changes in the weather and hormonal fluctuations.
MRIs and CT scans are typically not the first order of business in determing the root cause. It’s a big ordeal to sedate a child for an MRI, and it is not advisable to expose a child to radiation from a CT scan unless absolutely necessary. So a great first step is to be well-prepared when visiting the pediatrician by providing a detailed diary.
A headache journal should include the time of day the headache started, where the pain is, how long it lasted, what the child was doing at the time and what helped make it go away.
With this information, we can begin to rule out the things parents worry about most—notably, brain tumors.
Brain tumors are incredibly rare, affecting approximately 2,000 children a year in the U.S. Pediatricians can go their entire careers without seeing one. That being said, the incidence of brain tumors in children is on the rise, and we don’t know why.
Headaches caused by a brain tumor usually present with additional symptoms. A frontal region tumor may be associated with behavioral changes; a lesion in the back of the brain may be associated with difficulty with coordination; tumors in the area of the brain controlling speech or strength may be associated with alterations in these functions.
Headaches that occur in the morning may be associated with brain tumors, likely because of pressure building up while kids are lying flat at night, leading to morning pain.
Kids who are too young to speak have their own ways of showing distress. They grab their ears if they have an earache and they rub their eyes when they’re tired.
But it’s not normal if they’re grabbing at their head.
I just completed surgery on a 3-year-old boy whose astute mother noticed he would hold the back of his neck when he was running around. He was otherwise happy and playful, and he didn’t complain much about pain, but he shouldn’t have been holding the back of his head every time he ran.
He had a Chiari Type 1 malformation, a structural problem in the brain that is relatively rare, but more common than a brain tumor.
The brain is supposed to be contained within the skull, but if a portion of the cerebellum called the “tonsils” (not to be confused with the tonsils in the back of the throat) drops lower than it should, the result is a Chiari Type 1 malformation.
The classic symptom of a Chiari Type 1 malformation is short-lived pain in the back of the head and neck that worsens with “valsalva maneuvers”—forced exhalations while keeping the mouth and nose closed. So if a child says he has head pain every time he has a bowel movement, that’s reason to be concerned.
But sometimes a Chiari malformation doesn’t cause any symptoms at all. For every 20 kids I see in my office for this problem, 19 do not need surgery. When surgery is required, the intention is to provide more space in the back of the brain, which will ease symptoms and decrease the possibility of potential problems in the future.
In general, parents should keep two things in mind when considering kids’ reports of headaches: young children complaining of head pain don’t usually have anything to gain by fibbing or exaggerating, and headaches that are consistently accompanied by additional symptoms should be checked out.
• Fast Fact: The brain itself doesn’t feel pain—it’s the nerves, blood vessels and muscles sending out pain signals.
Diary of a Headachy Kid:
• time of day it began
• location of the pain
• type of pain (throbbing? jabbing? steady?)
• how long it lasted
• activity at the time of onset
• what helped ease symptoms
Dr. Sandberg is Associate Professor and Director of Pediatric Neurosurgery University of Texas Health Science Center at Houston, Children’s Memorial Hermann Hospital and Mischer Neuroscience Institute.