Headache is a frequent, disabling occurrence in children and adolescents. Migraine affects 11 percent of persons between the ages of five and 15, while tension-type headache occurs in 1 percent of persons in this age group.¹ Migraine prevalence peaks at 12 years of age, and these headaches affect 19 percent of children who are 12 years of age.¹ In a recent survey of U.S. high school students, more than 20 percent of adolescents reported having weekly headaches, with 11 percent of girls and 3.5 percent of boys reporting daily headaches.² Children with headache lose 7.8 instructional days per school year compared with 3.7 days in children without headache.²

As Dr. Lewis highlights in an article in this issue of American Family Physician,³ a comprehensive treatment approach to headache—medication supplemented by a reduction in psychologic distress and behavior modification—is often valuable. Significant personal stressors (e.g., family separation, moving, death) occur within 12 months of headache onset in 73 percent of adolescents.⁴ Depressive symptoms are reported by 86 percent of teenagers with daily headache.⁵ Depressive symptoms and low self-esteem are premorbid predictors of adolescent headache in girls.²

In children with significant school absenteeism, possible contributing psychosocial stressors such as school, family, or relationship problems should be investigated. Migraine occurs more often in children who report feelings of unhappiness, fear of school failure, or fear of a teacher.⁶ In addition, feeling bullied is associated with frequent headache episodes in children between seven-and-a-half and 10 years of age.⁷ Frequent school absenteeism is a significant stressor that results in a decrease in academic performance, social interaction with peers, and self-esteem. These factors often aggravate pain perception.⁸

When treatment begins, resumption of regular routines should also occur. Caregivers should assure that the child or adolescent does the following:

• Maintain a regular bedtime. Children should be in bed no later than 10 p.m. If unable to sleep, they can listen to a radio or read a book. Watching television or snacking after bedtime should not be permitted.

• Maintain a regular rise time. Allow adequate time to prepare for school. Regular bedtime and rise times should be maintained for all children, including those who are home schooled.

• Maintain regular mealtimes.

• Maintain a regular homework time and location. Homework should not be done while watching television.

• Maintain enjoyable leisure activities. Encourage activities that include socialization and physical activity while limiting computer, video, and television time.

Good school participation, including regular attendance, must be a top priority. School is important for social, emotional, and intellectual development. If a child or adolescent has been unable to attend school, physicians and caregivers should work with the school nurses, guidance counselors, and teachers to facilitate a return to school and to maintain attendance. A return to school can begin with attendance at low-stress classes and lunch period.

If headaches occur during the school day, the child should be allowed to leave the classroom to go to the nurse. The nurse may administer prescribed medication and facilitate pain management techniques such as those described here. Unless the child is vomiting, he or she should return to the classroom after 15 to 20 minutes.

Psychologic skills, such as cognitive training, stress management, relaxation, and biofeedback, are particularly beneficial in children and adolescents.^9–12 The following techniques can be as effective as standard medication therapy:¹¹

• Cognitive training. Cognitive training helps change negative perceptions of headache and reduces catastrophic thinking, which may increase the occurrence of headaches.

• Relaxation techniques. Relaxation techniques such as progressive muscle relaxation, cue-controlled breathing, and biofeedback should be taught by trained personnel. The use of self-help books and relaxation tapes without professional training is usually not effective.

Exercise instills a feeling of general well being and may reduce chronic headache.^13,14 Exercise should include stretching and general aerobic exercise at least three times a week. Physical education classes can count as one day of aerobic exercise. Stretching exercises involving the neck and shoulder girdle should be done twice daily. In addition, flare management techniques (e.g., oscillatory movements, positional distraction, and trigger point compression) can be taught by a physical therapist.

The parents' role in this process is not to get rid of the child's pain, but rather to assure that the child gets up, gets dressed, and gets to school every day unless the child is vomiting. Parents also need to reinforce and encourage participation in normal activities.

The child should be encouraged to focus on positive elements about himself or herself—being a musician, an athlete, a good student, a scout, etc.,—rather than focusing on the headache. The headache should be only a small part of the child's identity. A combination of caregiver support, behavioral techniques, and effective medication can improve headache and its associated disability in most children and adolescents.