Headaches are a painful symptom; however, because others often struggle to understand the severity of the pain, many children suffer in silence. When medical examinations reveal normal findings and the cause remains unknown, children who experience recurring headaches may face physical and mental strain. Children who complain of chronic headaches suffer from worsening headaches caused by a combination of physical (primary headaches such as migraines and tension headaches), psychological (mental state, self-esteem, etc.), and social factors (school and home environment and relationships with friends and family) factors.

 Thus, how should we manage children who appear to be experiencing headaches? We propose a response based on the biophysical social model, which focuses not only on treating physical factors with medication but also on psychological and social factors. Rather than desperately trying to eliminate “headache,” how patients will live their lives after leaving the examination room must be carefully considered.

1. Overview and definition

 Here, functional headache is defined as “a type of primary headache (not secondary) that is highly socially disruptive and recurrent.”

 Headaches, such as migraines and tension-type headaches, are called primary headaches, whereas headaches caused by brain tumors, sinusitis, influenza, and other infections are called secondary headaches. “Functional headache” is not an official medical term listed in the International Classification of Headaches. However, this term is commonly used in clinical practice to describe primary headaches, which means that headaches without an identifiable underlying disease.

 Although not an official medical term, “chronic daily headache” is often used in clinical practice to describe chronic headaches. Chronic daily headache is a concept proposed by Silberstein et al., defined as headaches that occur ≥15 days per month for ≥3 months. Functional headaches that progress to chronic daily headaches can lead to truancy and irregular school attendance, causing significant social impairment.

2. Epidemiology

 Migraine headaches are reported to occur in 3.5% of elementary school students, 4.8%–5.0% of junior high school students, and 15.6% of high school students. Despite the lack of sex difference among elementary school students, the prevalence in girls increases after puberty. Tension-type headaches are the most common type in Japan, with a prevalence of 5.4% among elementary school students, 11.2% among junior high school students, and 26.8% among high school students. The prevalence of chronic daily headaches ranges from 1% to 4.5%, with girls being 2–3 times more likely to experience chronic daily headaches than boys.

3. Causes

 The mechanism of migraine headaches has been gradually elucidated in recent years, but research is still ongoing. First, various stimuli, such as bad weather, stress, and disrupted sleep patterns, induce the secretion of neurotransmitters that act on blood vessels (calcitonin gene–related peptide and substance P) from the terminals of the trigeminal nerve, which controls facial and head sensation. These neurotransmitters then cause inflammation around the nerves and blood vessels on the brain surface (dura mater), causing the blood vessels to dilate and resulting in pain associated with migraines.

 The mechanism behind tension-type headaches remains unclear but is thought to involve impaired pain mechanism due to peripheral (the nerves are sensitive to pain) or central (the brain is sensitive to pain) sensitization.

 In children, functional headaches are exacerbated by a combination of physical (primary headaches, such as migraines and tension headaches), social (school and home environment), and psychological (mental state, self-esteem, etc.) factors. Although thorough examination of whether any underlying diseases cause headaches is essential, treatment should address not only the physical aspects but also social and psychological factors.

4. Diagnosis

 Underlying diseases that could cause headaches, such as brain tumors, should be carefully evaluated. The SNOOP checklist is used to identify red flags for secondary headaches (Figure 1). Warning signs of serious headaches in children are presented in Figure 2.

 Organic causes of headaches include neurological (such as brain tumors), otolaryngological (such as allergic rhinitis and sinusitis), ophthalmological (such as vision loss), endocrine (such as thyroid disorders), oral and maxillofacial (such as dental caries and temporomandibular joint disorders), and internal medicine (such as hypertension and anemia) disorders. The exclusion of these organic causes is a prerequisite for the diagnosis of primary headaches. Simply ruling out these conditions may lead to relief. Based on this, we have used the International Classification of Headache Disorders, 3rd Edition, to diagnose migraines and tension-type headaches.

 Migraine pain is a severe headache that gradually worsens and is exacerbated by physical movement. In children, migraine is often accompanied by nausea and vomiting. Migraine typically presents as a throbbing headache; however, children cannot clearly define the throbbing and unable to describe it due to their young age. The headache lasts 4–72 h; it is shorter in children than in adults and may be as short as 2–3 h. Since light and sound sensitivity often accompany migraines, this was confirmed using easy-to-understand expressions such as, “Do you find bright lights unpleasant?” or “Do you find loud noises unpleasant?” As a precursor to the headache, symptoms such as seeing sparkling lights, blurred vision, or “objects appearing larger/smaller, distorted, or mosaic-like (Alice in Wonderland syndrome)” may also occur. A headache is considered migraine when it is severe enough to limit activity and is accompanied by nausea, vomiting, or sensitivity to light and sound. Objective indicators must be assessed, such as pallor, lying down, preferring a dark and quiet environment, or ceased playing their favorite games (Figure 3).

 Tension-type headaches are characterized by symptoms such as “a feeling of tightness around the head” or “a heavy feeling in the head.” Although its pain is less intense than that of migraines and does not typically interfere with daily activities to the extent of causing severe discomfort, they can be dull and continuous. Among children who complain of daily headaches, some may have OD, which can be a contributing factor to the headaches. These headaches often peak in the morning after waking up and improve in the afternoon or evening. They are accompanied by autonomic symptoms such as dizziness, lightheadedness, fatigue, and difficulty waking up. Owing to morning discomfort, school tardiness and absences may increase, potentially leading to truancy. Diagnosis is made through an orthostatic test.

 Frequent headaches can lead to increased use of painkillers, which can result in “medication overuse headaches.” This type of headache is diagnosed when painkillers are taken for >15 days per month (or >10 days per month, depending on the medication) for >3 months. Care must be taken not to exceed this standard, as this condition can occur with both prescription painkillers and over-the-counter medications.

 The “fear-avoidance model” has been proposed to determine factors contributing to chronic headaches. This model suggests that pain catastrophizing, characterized by repetition (constantly replaying the pain in one’s mind), magnification (exaggerating the intensity of pain) and hopelessness (believing there is no escape from the pain), leads to fear and anxiety about pain, resulting in avoidance behaviors (such as truancy), which in turn exacerbate headache episodes (Figure 4). It is important to               be mindful of whether an individual is caught in such a vicious cycle. Additionally, questionnaires such as the 30-item Questionnaire for Triage and Assessment, Strengths and Difficulties Questionnaire, Attention Deficit/Hyperactivity Disorder Rating Scale, and PRAS-TR may be useful in identifying cognitive characteristics, developmental traits, and background factors that predispose individuals to such states.

5. Treatment and countermeasures

  The biophysical social model in the treatment of chronic headaches is shown below.

Biological: To relieve painful headaches.

 Nonpharmacological therapies, such as lifestyle guidance, are fundamental to the treatment of any type of headache. Eating three meals a day, getting good quality sleep (neither too little nor too much), exercising moderately, and maintaining a regular lifestyle are effective in preventing and treating headaches. In recent years, the use of smartphones and tablets has increased even among children, and although they are indispensable in daily life, their use must be avoided 1–2 h before bedtime.

We ask patients to keep a headache diary to identify migraines that may be masked by chronic headaches and explain the importance of taking pain relievers promptly. Pain relievers should not be taken preventively (such as taking them to avoid headaches) but should be taken early at the onset of pain. Taking medication after pain peaks may be less effective. For pediatric migraines, ibuprofen or acetaminophen is often effective, and combining them with antiemetics can enhance their efficacy. During a migraine attack, stimuli such as light or sound can worsen the headache; thus, resting in a dark, quiet room and applying an ice pack to the painful area can help reduce pain.

Psychological: To reduce anxiety among patients and their parents

 If a child complains of daily headaches without signs of serious illness, presents with varied symptoms, and responds poorly to medication, it may be helpful to assess the child for any psychological or social stressors. Even if symptoms persists, it is important to avoid repeatedly changing medications, using strong pain relievers such as loxoprofen or diclofenac (not ideal for pediatric use), frequently adjusting preventive medications, or combining multiple drugs.

 Importantly, pain is real for the child. We must avoid dismissing it as simply a “mental issue” and instead strive to understand the child’s pain.

 The concept of the “pain vicious cycle model (Figure 4)” of the child and their family states that “repeatedly recalling pain, feeling it more intensely than necessary, and the fear and anxiety of being unable to escape pain can lead to avoidance behaviors (such as truancy), which further exacerbate headache episodes.” Alongside nonpharmacological and pharmacological treatments, the cognitive–behavioral therapy (CBT) will be implemented for headaches.

 Specific methods of CBT include having the child keep a headache diary to gain a deeper understanding of the headaches and their causes and alleviating the child’s anxiety by alleviating the headaches through appropriate examinations, diagnoses, and treatments.

Social: To address issues in the child’s home and school environment

 As treatment for the aforementioned physical and psychological factors progresses and the child learns to cope with the symptoms, a sense of mental ease gradually emerges, leading to “realization” by both the child and his/her family. If possible, medical interviews are conducted with the child alone, information is gathered from family members, friends, teachers, and other sources, and collaboration is sought from multidisciplinary professionals (such as nurses and psychologists) to assess the presence of any issues in the child’s environment, including school-related issues (such as bullying), family-related issues (such as parental conflict, economic circumstances, and abuse), and other environmental factors.

 During the examination, review the headache diary with the patient and work collaboratively to reflect on symptoms, thereby building a trusting relationship with the patient. Encourage the patient by saying, “It must be difficult to deal with headaches every day, but you’re doing a great job.” Consider what can be done now, even if the headaches cannot be completely eliminated. “Let’s start with a 15-minwalk,” or “since you’re feeling much better, let’s aim for two afternoons a week at school.” Supporting the child and taking small steps gradually increase the number of desirable behaviors for the child.

6. Conclusion

 Headaches are a major global health burden, with economic losses in Japan estimated at 2 trillion yen and ranked second among diseases that shorten healthy life expectancy in the World Health Organization 2016 Years Lived with Disability rankings. This is true for both adults and children.

 We hope awareness of “children’s headaches” will increase and that both children with and without headaches support each other and live healthy lives.

TAKESHITA, Mika

Tokyo Medical University Hospital, department of pediatrics and adolescent medicine/ Fujino Clinic, internal medicine and pediatrics