Chapter 1: What You Can Do to Help Children Get ReliefHeadaches: Why Everyone Needs to Learn More About Them
With painstaking attention to detail, Jonathan carefully places his miniature toy soldiers one by one on the floor of his bedroom. Almost as if afraid the slightest movement or even the gentle force of his breath may knock them down, he sits rigidly still with only his eyes following his tiny hand as it picks up each soldier from the toy box and places it in line. His eyes move back and forth from the box to the floor without stopping until all the soldiers have been arranged. When he is finished, he has created a triangle of twenty-one soldiers standing in six precise rows: six soldiers in the back row, five in the next, four, three, two, and one in the front row. Remarkably, each soldier and each row are one inch apart, as if following to the exact tolerances of an architect's blueprint. He is young to be exhibiting the migraine sufferer's compulsive neatness.
As he worked, four-and-a-half-year-old Jonathan has become less and less responsive to anything in his external environment. He doesn't move or say a word when the clock in the family room begins chiming, a sound that would normally alert him to the hour of his favorite television program. He remains motionless when his sister, Jessica, calls him repeatedly, in louder and louder tones, to come out and watch the show. He does not react to his father's presence at the door to his room or when he enters and tells Jonathan that his friend Daniel has come by to watch TV.
By this point, little Jonathan has grown very pale and tears have begun to well up in his eyes. He rises slowly from the floor and lies down on his bed, clutching his head with one hand and his stomach with the other. Seconds later, as his father kneels by his bedside to stroke his hair, Jonathan throws up in a basin his father has pulled out from under the bed. Just at that moment, Daniel walks into the bedroom.
Jonathan's father quickly covers his son with a blanket, kisses his forehead, shuts off the light, and whisks Daniel and the basin out of his son's room, shutting the door behind him. He informs Daniel that Jonathan is having another one of his "headache attacks" and needs to "sleep it off." He apologizes for his son's condition, and tells Daniel to come back another day when Jonathan is feeling better.
Daniel leaves feeling rejected. After cleaning the basin, Jonathan's father is concerned as he joins his daughter in the family room, sighing and shaking his head as he sits down to watch TV. Seven-year-old Jessica complains to her father about Jonathan's being sick again and her having to do his chores as well as her own. In short, Jonathan is ill, his friend is hurt, his father is worried, and his sister is annoyed.
Jonathan suffers from his headaches, but so do many of the people around him. He is hurting in ways that he may not yet have the vocabulary to describe adequately. Without proper explanation or understanding of his headache, the others in his life are suffering as well, and they may not be able to express what they are feeling any better than Jonathan can.
Education is a powerful tool in the fight against headache disorders. The more knowledge we can acquire, the greater capacity we will have to understand and help those affected. We will return to Jonathan's story in chapter 2 for a discussion of his particular headache disorder and the role of education in his successful treatment.Attitudes About Headaches
From the beginning of civilization, various social, cultural, and family attitudes have developed regarding the appropriate way to act when in pain. Many of us have learned that we have to be brave in the face of pain -- "take it like a man" and not talk about it. As a result, we have seen many adults who have suffered in silence for years before seeking medical attention for their headaches. Some of these patients have been told by friends, family members, or even doctors that their headaches are "no big deal" or that they "just have to learn to live with them." Others have been told, "It's just a headache. Get over it!" Patients tend to internalize these harmful messages and, in turn, develop the fear that if they speak about their pain, they will appear weak or fragile. Many have waited to get help until the headache pain is so bad that it has affected every part of their lives. Sadly, others never get help at all.
Because of the attitudes that many adults hold about pain, and specifically about headaches, children's headaches may be ignored by their families -- and sometimes even their doctors -- as passing phases of childhood or attention-getting behavior. Too often misdiagnosed, their headache disorders are undertreated, incorrectly treated, or not treated at all. These children suffer needlessly. As we have seen in Jonathan's case, everyone suffers -- not just the child.
An adult who suffers from chronic pain probably finds that it interferes with normal activities, such as socializing, working, eating, sleeping, and having sex. When life is so restricted, the sufferer often also feels anxious and depressed.
Chronic pain in children could have far-reaching effects on their personality and skill development. Young children may cry, rock, or hide when they experience pain. As they get older, they may experience anxiety and depression, as well as have difficulties eating, sleeping, and playing. They may have trouble focusing their attention on learning at home or in school, and this may result in behavior problems.Headache is a widespread problem not to be taken lightly
whether in adults or in children. Reports have estimated 68 percent of patients seen by neurologists complain of headache. As previously mentioned, according to the latest conservative estimates, at least forty-five million Americans experience some form of headache on a recurrent basis. Just as severe and/or frequent headaches in adults can often be disabling -- interfering with family, social, and work activities and relationships -- headaches in children can similarly affect a child's family and social interactions, and his or her capacity for attendance and performance in school.
The following table illustrates the results of a 1997 to 1999 survey of three hundred children with headache being treated at the Cleveland Clinic by Dr. David Rothner. The large proportion of children experiencing migraine headaches is typical of what is seen in private practice.
The good news is that most headache patients -- adults and children -- can be helped if we do the following three things:
Adopting Healthy Attitudes About Pain
- Change our attitude about how we deal with pain.
- Ask the right questions so that we can supply medical personnel with the most complete information possible.
- Find doctors who are sufficiently well trained in the diagnosis and treatment of headache disorders to use this information wisely, identify the problem, and offer reasonable solutions.
Before we can expect to find ways to manage pain, we need to acknowledge that it exists. We must recognize that pain is part of the human experience and, like any other human experience, is accompanied by an array of emotions. Both the sufferer and the observer will have feelings about the pain and how it has affected their daily lives. These feelings -- such as fear, anger, sadness, frustration, guilt, and resentment -- need to be expressed in order for healing to occur.
While we encourage discussions among patients, family members, friends, teachers, and so on, it is important for everyone to remember that descriptions and feelings about pain are difficult even for adults to express.
Since most adults seek approval from those around them, negative comments from others may prevent them from admitting certain facts about their pain, such as its true severity or duration. Since only truthful descriptions of pain will lead to healthier attitudes, as well as appropriate treatment, it is crucial that discussions with children about headache be as sensitive, open, loving, and nonthreatening as possible.
We often break the ice in such discussions by asking the children to draw pictures of their pain. We find this is a helpful way for patients or others to freely express their experience of the pain. Even a simple drawing can often provide important information about the symptoms and emotions that accompany the headache.
Once the parents acknowledge that the pain exists and we have begun to discuss it openly, we also need to acknowledge that headache pain is a problem that we may not be able to deal with alone. Parents need to give their children permission
to seek medical help and support when pain is experienced and becomes troublesome.Asking the Right Questions
It is important to keep in mind the old adage "What you put into life is what you get out of it" when making that first trip to the doctor's office. Preparation for this visit is an important key to its overall success.
The most important tool that doctors have in making the proper diagnosis is a patient's medical history, which will be taken during that first visit. The patient and the accompanying parent (or guardian or other caregiver) will be asked a series of questions about the headache and general medical history. It is important to note that head pain, neck pain, and facial pain are all considered headache symptoms.
To ensure that the history taken in the doctor's office will be as accurate as possible, we recommend that relevant information about the patient should be collected before the initial appointment.
This information can best be obtained by carefully observing the child's behavior before, during, and after his headaches, and by asking the child about his or her headaches.Patient Medical History
The following questions will help to establish the patient's headache and general medical history. We highly recommend that all of these questions be answered and brought to the first appointment. For your convenience, the patient medical history is reprinted in appendix A. Feel free to write your answers directly on those pages, or you may wish to photocopy the pages.
Sifting through the data from a patient's medical history is much like putting a large jigsaw puzzle together. A strategic piece must first be chosen. Then additional pieces can be evaluated for their proper placement in the puzzle until eventually the whole picture takes shape. The first strategic piece of the puzzle of headaches is to determine whether the patient suffers from one or more than one type of headache. Once this is known, the doctor can evaluate all other data for their relevance to the total headache picture. When the picture becomes clear, a treatment plan can be prescribed and implemented.
The first question, then, should be: Does the patient have one or more than one type of headache? Ask the child if all headaches feel basically similar to one another or if some feel different. For example, one type may be described as an occasional throbbing headache that occurs only on one side of the head and is accompanied by nausea and vomiting. Another type of headache may be described as a daily dull ache throughout the entire forehead that is not accompanied by other symptoms.
The doctor also needs to know how the headaches have been treated -- what past and current headache medications were used -- and what studies or tests have been performed. It is important to bring results of any prior tests to the headache evaluation appointment. After taking a medical history, the physician will perform physical and neurological examinations.
For each type of headache the patient describes, it is necessary to collect as much information as possible on the headache.
Finding the Right Doctor
- How old was the patient when the headache began?
- Were there any noteworthy circumstances that occurred at that time? Was there some emotional conflict going on at home or at school? Was there a death or divorce in the family? Did the child suffer a physical trauma, such as a fall or blow to the head? If the child is female, did the headache begin before or during her menstrual periods?
- Do the headaches occur only or primarily at certain times of the year?
- Is there a relationship between weather and the headache?
- Do the headaches occur most often on weekends or holidays?
- Do the headaches occur at a particular time of day? For example, do they always occur early in the morning or wake the child from a sound sleep? Are they more frequent after school?
- What part or parts of the head hurt during the headache? Ask the child to describe in detail the location(s) of the pain. Draw a picture if necessary.
- Are there other symptoms in the head or elsewhere in the body that are associated with the headache? Does the child see flashing lights, zigzag patterns of color, or any other unusual visual changes that warn him a headache is about to occur? Is there any weakness or numbness in his face or body? Does the child's speech become difficult to understand? Does he feel abdominal pain or nausea? Does he vomit or have diarrhea? Does the child become pale or have cold hands? Do any of the associated symptoms persist after the headache is gone?
- Does the patient become unusually sensitive to light, sound, smell, or touch before, during, or after a headache? Is the patient aware of any other sensitivity associated with the headache?
- How often do the headaches occur?
- Has this frequency changed? Is there a specific pattern?
- If the child's headaches have a clearly defined beginning and ending, how long does each one last? How long did the longest and shortest headaches last?
- Does the intensity of the headache vary throughout the day?
- How severe is the headache on a pain scale of 1 to 10 (with 1 being the most mild and 10 being the most severe)? Are all headaches about the same degree of pain, or do they vary from one headache to the next? Using this scale, what number is characteristic of the worst headaches? What number is characteristic of the mildest headaches?
- How does the child describe the pain? Throbbing, pulsing, pressure, or tightness?
- Has the severity of the headache changed over time? Has the headache pain or other symptoms worsened since the first one was experienced?
- How disabling is the headache? Does the headache restrict the child from participating in school, family, or social activities?
- Does the child's behavior change before, during, or after the headache? Does the child become quiet or unable to concentrate? Does the child rock or hold on to some part of the head? Does the headache change the child's appetite or sleep patterns?
- Are there any premonitions about the headache before it starts, such as fatigue or energy, increased or decreased appetite, quick temper, etc.?
- Does the child have difficulty in falling asleep? Does he awaken often during the night or early in the morning?
- What things make the headache worse? Does the headache occur after eating specific foods, taking certain medications, or doing different types of activities? For example, some children might notice that they get a headache after eating chocolate. Some may get headaches after taking decongestants to clear up a stuffy nose. Others may indicate that their headaches come on after overeating or engaging in too much exercise or other physical activity. Do changes in weather, temperature, or altitude affect the headache?
- Does the headache occur or worsen with straining? It is extremely important to speak with a doctor as soon as possible if a headache occurs or worsens substantially with straining, such as during a bowel movement or when coughing or sneezing.
- What things make the headache better? What does the patient do during a headache? Does the child prefer to lie down in a dark, quiet room? Does a warm bath, a cold compress, a massage, or over-the-counter pain medication help relieve the pain?
- What prescription and nonprescription medications does the patient take for the headache or associated symptoms such as nausea? Which one works best? Which ones are least effective?
- If over-the-counter medications are used, how long does a bottle last?
- Does the patient take vitamins, herbal medications, or any other type of alternative medication? If so, which ones?
- Do certain foods trigger headaches? If so, list them.
- Have there been any major changes in diet recently?
- How much caffeine is consumed daily? Caffeine is found in colas, chocolate, and tea.
- For girls -- is there any relationship between the headache and your menstrual cycle? If so, at what point in the cycle does the headache occur?
- Does the child take birth control pills?
- Did the biological mother of the patient experience a normal pregnancy, labor, and delivery? Describe any known complications.
- Has the general growth and development of the patient been normal? Describe any known problems.
- Does the child have other medical problems? If so, list them. Does the patient take medications for these conditions? If yes, which ones?
- Does the patient have any known allergies or sensitivities to foods, medications, cigarette smoke, and so forth? Has the child ever been treated for allergies? Has the child ever been exposed to substances that provoked his or her allergic symptoms?
- Has the patient ever been diagnosed with depression, anxiety, or any other emotional disorder? If so, was the child treated with medication, sent for counseling, or hospitalized for this condition? List medications, type and length of counseling, and length and number of hospitalizations.
- Has the patient had any surgeries? If so, list them.
- Has the patient ever used marijuana, cocaine, alcohol, or other drugs?
- Have any tests been done to evaluate the child's headaches? Have blood tests, CT or MRI scans, EEGs, lumbar punctures, or other tests been performed? List each test with results, if known.
- List any parent, grandparent, or sibling of the child who has or had: headaches
epilepsy or other seizure disorder
heart disease or hypertension (high blood pressure)
connective tissue disease
- Has the child been seen by other physicians for headache? If so, list the names of the physicians and dates seen.
- Has the child been hospitalized for headaches? If so, list hospital, names of attending physicians, and dates.
- Has the patient ever been to the emergency department for headache treatment? If so, please list dates and names of physicians.
Proper diagnosis is critical to proper treatment. We therefore advise that you consult a doctor who has dedicated a large part of his or her practice to the treatment of headache. Many doctors have established clinics with this goal in mind. Currently, there are more than eight hundred such specialty clinics in the United States.
In 1970, a group of concerned physicians established a nonprofit organization known as the National Headache Foundation (NHF) with the following major goals:
- to serve as an information source for headache sufferers, their families, and the health care practitioners who treat them
- to promote research into potential headache causes and treatments
- to educate the public that headaches are serious disorders and sufferers need understanding and continuity of care
This organization, as well as others we have listed in chapter 14, can help you find doctors in your area who specialize in the treatment of headache. At the present time, such doctors may have degrees in many different areas of medicine. For example, pediatricians, internists, general practitioners, and neurologists may all treat headache patients. For the best care, it is wise to locate doctors who have successfully treated a large number of headache sufferers, many of whom are children.
During the first appointment, the doctor's major goals will be to:
Beyond the Doctor's Office
- examine the child
- ask the child and the accompanying adult questions about the nature of the headaches
- decide if further evaluation is necessary
- establish a preliminary diagnosis
- prescribe appropriate medications and/or other therapies
- educate the child and accompanying adult about the diagnosis and possible ways to prevent and/or treat the symptoms
- schedule a return appointment to evaluate the success of treatment
Beyond the skill of the doctor to appropriately diagnose the patient's headaches, successful treatment depends on the extent to which the patient, doctor, caregivers, family members, and friends work together to create and maintain management solutions. There is no cure for headaches and no one "right" drug or other solution for every headache sufferer or for every type of headache. It also is impossible for a doctor to predict exactly how effective any given treatment will be until it is tried. Thus, finding out what works for one patient is a matter of trial and error -- a fact that can be no less frustrating for the doctor than for the patient and other involved parties.
In the chapters to come, we will learn more about headaches and what can be done to keep them under control. We will see time and time again that changing attitudes about pain, asking the right questions, and finding the right doctors can make a world of difference.
Copyright © 2001 by Seymour Diamond, M.D.