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Video Transcript: Headaches in Children

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. Almost everyone has experienced a headache. But, do you know that children get headaches as well. We'll learn about headaches in children and how they can be treated.

My guest is Dr. Jack Gladstein. He's a pediatrician and director of the Pediatric Headache Clinic at the University of Maryland Hospital for Children. Dr. Gladstein is also an associate professor of pediatrics and neurology at the University of Maryland School Of Medicine.

Welcome to the show.

Jack Gladstein, M.D.: Thank you. Glad to be here.

Ellen Beth Levitt: Are headaches pretty common in children or are they rare?

Jack Gladstein, M.D.: Headaches are common in children. Maybe about 5% of children have headaches or maybe even migraines and teenagers it goes up to 10%. A lot of people don't think their children should have headaches. So, they get nervous when their child has a headache. It's common and benign.

Ellen Beth Levitt: What causes headaches?

Jack Gladstein, M.D.: It's mostly a genetic disease. And migraines are a genetic disease. One or more parents have migraine. You need to have the right or wrong genes are the first step. And then there is some sort of trigger. The trigger happens and then you get a headache.

Ellen Beth Levitt: How come some people never have a headache when they are a child and later in adulthood they might experience migraines, for example?

Jack Gladstein, M.D.: What happens you brew a potential for migraine and some people live that potential in their children, some wait until they are teenagers and some wait until they are adults. It's still a young person's disease. If somebody gets a bad headache for the first time in the '50s or '60s then we worry about bad things. But if somebody has their first headache as a youngster usually it's benign.

Ellen Beth Levitt: I guess migraine is something that a lot of people have heard about. Is that the most common type?

Jack Gladstein, M.D.: Migraine is the most common. It's the one that doctors will see in their office for the most part. People get fooled. They think they might have other things like tension headache or sinus headache. But, most of the time it turns out to be migraine. The thing about migraine is that it's episodic. So, in between your headaches, you are perfectly fine. The headache is usually really bad. It can be accompanied by nausea, vomiting and lights and sound sensitivity. The main thing is to ask if anyone in your family has it. Yeah, yeah someone else has headaches. Migraines are the common one. And the others tend to fool you.

Ellen Beth Levitt: To fool you?

Jack Gladstein, M.D.: For example, people who have headache in the back of their neck are convinced that they have tension headache. But, when you ask them they say the light bothers me, the sound bothers me; I need to lie in a quiet room for a few hours. The fact that the headache's in the back of your neck doesn't mean anything.

Ellen Beth Levitt: So, here we have a picture that depicts the types of headaches might feel like or where the focus of the pain might be. But, you are saying with a migraine you could have the pattern shown in any of these pictures?

Jack Gladstein, M.D.: That's correct. There was a study done out in California. They took all chief complaints of headache from thousands and thousands of people. If they said that they had migraine their final diagnosis was migraine. If they said I think I have tension headache their final diagnosis was migraine. In fact, people that go to the doctor for headaches 94% of the time it are going to end up being migraine. It doesn't matter if the pain is in the front or back it doesn't matter the location. If you are sick enough if seek medical care, it's a migraine.

Ellen Beth Levitt: That's not to say that people get tension headaches or sinus headaches that type of thing.

Jack Gladstein, M.D.: That's right. But, people tend to be fooled. If you are having recurrent pain doesn't worry about the location as much.

Ellen Beth Levitt: Do children experience the same types of symptoms of a migraine as adults do?

Jack Gladstein, M.D.: They do, except parents believe that children shouldn't get migraines. School teachers don't think children should get migraines. School nurses think children don't get migraines. So, often, when kids get a headache one reaction is to overreact and worry that everything is a brain tumor. The second reaction is that you are faking, because kids shouldn't get headaches. You get it from both ends. The kids' headaches tend to be more bilateral, where adults tend to get a headache on the one side. But the kids can still get pain in the back of their neck or have the sinus fullness that adults can get too.

Ellen Beth Levitt: If you have a child complaining of a headache what should you do? What are the symptoms that is would make you concerned well, maybe we should get this checked out. You said there are serious things that can cause headache that are not a migraine?

Jack Gladstein, M.D.: The elephant in the room is that every parent is convinced that their child has a brain tumor. That is the thing the doctor must address.

Ellen Beth Levitt: That's the big worry that people might have as soon as their children are complaining of a terrible headache.

Jack Gladstein, M.D.: So, the good news is the worse the headache, the more benign it is. So, if your headache is horrible it probably going to end up being migraine. Now, migraine is episodic, but if somebody has a headache every single day that needs to be looked into. Now, somebody could be stressed out or somebody is having trouble in school or serious psychological stuff going on. But, everyday headache needs to be looked into. Severe intermittent headache, take your time and get to your doctor. The rule is six months of intermittent headache and a normal exam, it's a benign condition.

Ellen Beth Levitt: Are there imaging tests that you can use to diagnose what's going on?

Jack Gladstein, M.D.: It's a talking field. A good history, a good physical exam and most the time you don't need any tests, which is great, because tests tend to confuse you. MRIs are wonderful tools in the right hands, but they find so much stuff that just scares people. The beauty of doing a good history and a good physical exam and keeping your hands behind your back and not ordering tests is the way to go. It saves money and time and a lot of aggravation.

There are two peaks for headaches in kids. The first peak is age six and the second peak is around puberty. So before puberty, migraine is a disease of boys and girls of equal amount. From puberty on, it becomes a girl's disease. One of the main culprits is the drop of estrogen. There are more girls that have migraines than boys when they start to menstruation.

Ellen Beth Levitt: Why would hormones affect if you get a headache or not?

Jack Gladstein, M.D.: It's the sudden drop of estrogen that can take someone who is predisposed to having a headache to have a headache. Everyone can have a headache. The thing about people with migraine is that they have a genetic susceptibility that the same trigger that wouldn't cause any trouble causes trouble in somebody that does. If you have the genetic predisposition and you have that drop in estrogen, you can get that migraine.

Ellen Beth Levitt: Are boys as likely to get migraines as girls?

Jack Gladstein, M.D.: If they get them before puberty, yes. After puberty it becomes more of a girl's problem. There are plenty of adult males that get migraines too. For the most part if you go to adult headache clinics it's populated 80 to 90% by women.

Ellen Beth Levitt: What are the symptoms other than my head hurts of a headache in a child. Do they describe their symptoms differently from an adult who have migraines?

Jack Gladstein, M.D.: They can draw them beautifully. Sometimes instead of asking is it knife--like or throbbing, they look at you like you are crazy. They just say it hurts. So, here's a pen and a piece of paper, draw to me what you look like when you have a headache. It's great. They night draw a spear or a hammer. They might show pulsation somehow. So, actually having them draw it is better. The other thing is to ask the parents what your child looks like when she is having a headache. That tells you the whole story. I don't know it puts the covers over her head and hides in the room and she tells me to turn off the lights and TV. I don't have anymore questions. It's migraine. Does the kid need to put their head down on a desk or to retreat. That tells me information too. So, you don't have to get the descriptive words, but paint the scene.

Ellen Beth Levitt: And nausea does that have something to do with it?

Jack Gladstein, M.D.: You want that to be described if you want to clinch the diagnosis of migraine. They may or may not vomit. They'll tell you they have light and sound sensitivity and need to withdraw to a dark, quiet place.

Do children have the visual symptoms that are adults have when they have migraines?

Jack Gladstein, M.D.: Only 5 to 10% of kids with migraines have this thing called aura. It could be flashing lights, wavy lines. It could be something bothering their vision. It's about 5 or 10% of the kids that get that. So, the absence of it does not mean that it's not migraine.

Ellen Beth Levitt: Does the pain come on suddenly or sneak up on a child?

Jack Gladstein, M.D.: Usually the kids have half an hour to 45 minutes from first twinge until the headache is full blast. I call that the window of opportunity. If you can treat it at first twinge, it's easier to treat than if you wait to make sure it's a terrible migraine, because it's much harder to treat later.

Ellen Beth Levitt: I guess you alert your patients and their parents to be on the lookout. If they have concern symptoms to know when it's time to take medication and not hope that it will go away.

Jack Gladstein, M.D.: And not just the family, but the school. Because a lot of kids get their headaches at school, kids with migraines need that free pass to be able to get up and get their medicine at first twinge. If the school says no wait five or ten or fifteen minutes before you get your medication there is opportunity lost and the kids miss school. We measure how kids do with their headaches based on their disability. And a kid's disability is not measured in how much work they miss, but how much school they miss. So, getting the school to be an active partner in taking care of a child with migraine is really one of the advocacy roles that parents and physicians can play.

Ellen Beth Levitt: That's an interesting point. What about stress? Is that somehow linked or causative for children to have headaches?

Jack Gladstein, M.D.: Yeah, my no show rate at the clinic goes from 10% during the school year to 50% in the summer.

Ellen Beth Levitt: No show meaning--

Jack Gladstein, M.D.: People that have appointments that don't come. There are more people that don't come during the summer. Their life is less stressed. Again you meet the genetic predisposition you have to have all the symptoms. The reason that they get the headaches is stress.

Ellen Beth Levitt: There is something psychological that can trigger them. It's not just a physical thing. Does it matter, I guess?

Jack Gladstein, M.D.: It's all connected. The mind and body work together. When we are stressed outside we get more colds and run down. The more run down the more physical stuff we get. We all react to stress differently. Somebody that is has a tendency for migraine during a stressful period gets more migraines.

Ellen Beth Levitt: Are siblings more at risk? You said it was a genetic thing. If the parents have it the child may likely have it as well. Does that mean siblings as well?

Jack Gladstein, M.D.: Yes. It's very rare that when I take a good history that I get one patient with migraine and nobody else in the family has it. If you ask the questions right, you'll find out that the parents and sibling or aunt and uncle have one too.

Ellen Beth Levitt: Do the headaches last the same amount of time in a child versus an adult?

Jack Gladstein, M.D.: No. kids' headaches are shorter. It took us a lot of hard effort to deal with the headache doctors in an international level to recognize that. We had to prove that by look at thousands of children. Migraine headache at least in children lasts over a shorter period of time.

Ellen Beth Levitt: How long would you say?

Jack Gladstein, M.D.: The average for adults is 4 to 72 hours and kids are 1 hour to 72 hours.

Ellen Beth Levitt: That's quite a range?

Jack Gladstein, M.D.: Right. If you are going to try to design trials of drugs to use in kids, if their headaches are going to go away anyway it's hard to prove that the drug will work. Dropping the time and still say that somebody has migraine you are more accurate with the drug us that you try.

Ellen Beth Levitt: Interesting. We have to take a break. When we come back we'll talk about treating headaches in children. So stay with us.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today. I am Ellen Beth Levitt. My guest is Dr. Jack Gladstein. He's a pediatrician and director of the Pediatric Headache Clinic at the University of Maryland hospital for children. Dr. Gladstein is also an associate professor of pediatrics and neurology at the University of Maryland School of Medicine.

What is a hospitalist?

Jack Gladstein, M.D.: It's a doctor who takes care of people in the hospital.

Ellen Beth Levitt: That makes sense.

Jack Gladstein, M.D.: Taking care of hospitalized people isn't so easy. There are new drugs to learn and treating people is different. And the doctor would come into the hospital and take care of you as well rush back to the office and rush back to the hospital. Maybe not give you the best of care.

Ellen Beth Levitt: The continuity--

Jack Gladstein, M.D.: The continuity is wonderful but the time needed to really delve into the problems wasn't really there. The knowledge of hospital medicine might not have been there. So we've adapted that in pediatrics now. There are pediatric hospitalists who take care of common things on our floor. They are really good about patient safety they know the ins and outs about hospitals. They dedicate their time to talk to families. They don't have to run back to the office or the clinic. They teach residents and nursing students and all the other things that go about in a medical center.

Ellen Beth Levitt: Is that a 24-hour program?

Jack Gladstein, M.D.: We are not there 24 hours a day. The house staff is. We are responsible 24 hours a day. We get calls to accept patients from other hospitals and make sure that is going well, provide the service necessary.

Ellen Beth Levitt: That's a new concept.

Jack Gladstein, M.D.: Yes.

Ellen Beth Levitt: Let's talk about treating headaches in children. What are some of the most effective treatments? Do things Advil, aspirin work?

Jack Gladstein, M.D.: I like to focus on migraine. If a child has migraine the first thing is to think about prevention. What you can do for the patient so they don't get another migraine. People with migraine have sensitive brains. They need to be treated more delicately. They need to eat regular and not miss breakfast. They need to get good and consistent sleep. So if they are out on the weekend, they have to wake up the same time on Saturday and Sunday and get a bite to eat and go to the bathroom and lie down. Keep their sleep cycle the same. The heat makes your headaches go up.

Ellen Beth Levitt: Really the heat can exasperate that? Or trigger -

Jack Gladstein, M.D.: People are delicate. So they are a little dehydrated. I tell people with migraines that they have to stay better hydrated than everybody else. So that's the first thing, migraine prevention and good habits.

Ellen Beth Levitt: Are there foods that you should avoid if you are prone to migraines?

Jack Gladstein, M.D.: The food list is gigantic. There was a girl about ten years ago. I said what do you eat? Bagels. Everything else she liked was on the migraine list. Her mom took everything away. That was the wrong thing to do. So, just be sensible about it. Look at list of migraine foods. Use them in moderation or take one away at a time and see if it makes a difference. If it doesn't make a difference, go ahead and eat what you want.

For adults, they are advised to stay away from caffeine or red wine or chocolate.

See if it makes a difference. For some people it does. For some people it's the quantity. Instead of drinking four or five cokes a day, if you go down to one or one Starbucks instead of eight maybe that fixes the problem for some people. There are those that believe strongly that you have to take away all the migraine foods. The problem is these are kids and teenagers fight with their parents about independence. If everything that they eat is a fight I don't know if you are helping people.

Ellen Beth Levitt: Once the headache starts to come on, you need to do something right away and not wait. What is it that they should do right away?

Jack Gladstein, M.D.: Use medications and use them properly. If you can catch a headache at first twinge you don't need fancy medicines. Over-the-counter medicines are fine. All the aspirins and things are wonderful at first twinge they are safe for children at proper doses. You end up using higher doses of pain medicine or hoping that some of it will be absorbed.

Ellen Beth Levitt: What do you mean that the stomach stops working?

Jack Gladstein, M.D.: When you are nauseous, things will sit in your stomach and not absorb. You try to get away from the lowest possible dose. When it comes to treating a migraine you often have to use the highest possible dose in an attempt to get the medicine to go through. The first twinge great to use over the counter stuff; once you are sick, you have to use bigger guns. There's pediatric indication, because the studies were not done right. They are safe in the right hands and should be used for people with bad migraines.

Ellen Beth Levitt: How are they given? Are they pills or patches? What are they?

Jack Gladstein, M.D.: All styles, most Americans like pills.

Ellen Beth Levitt: Of course.

Jack Gladstein, M.D.: The idea of a shot or a nasal spray is abhorrent to most Americans. 85% of migraine prescriptions are pills even though they are nauseous. The medicines comes in melts. You can use a melting preparation. The melts are still absorbed in the stomach. If the stomach is not working you are still out of the luck.

Ellen Beth Levitt: Are there side effects to the medicines?

Jack Gladstein, M.D.: There are. They are scary but they are safe. People might complain of chest pain. They are not having a heart attack. Sometimes people will feel if burning in their forehead. I tell people if they have the side effects that are great news. The medicine got absorbed in your bloodstream. You are going to feel better in a few minutes.

Ellen Beth Levitt: Do some have to take medicine constantly to prevent headaches? Is it so bad? There are adults that need to take medication on a continual basis.

Jack Gladstein, M.D.: Right. The problem is committing a child or a teenager to take medicine every day is a big step. All good medicines have side effects.

Ellen Beth Levitt: You wouldn't want to do it unless it was absolutely necessary.

Jack Gladstein, M.D.: They don't have to take medicine if they only have two headaches a year. But if they are isolated and their headaches are taking over, then it's time to do either a medicine or a non-medicine, something that they do every day. Non-medicines are stuff like relaxation, hypnosis, and biofeedback. All those things work great.

Ellen Beth Levitt: You were talking about the role of stress and how that plays a big role in triggering the headaches in children. What about exercise? Do you encourage that?

Jack Gladstein, M.D.: Absolutely, as long as they hydrate. It's great and a way to release the stress and make your pleasure chemicals come out. We call them endorphins. And obese kids have harder to treat headaches. You tell everybody to stop smoking anyway but they don't link it to migraines.

Ellen Beth Levitt: Is there something that goes around the brain that causes headaches?

Jack Gladstein, M.D.: 20 or 30 years ago that is what we thought migraine was. We thought vessels contract and expand. It's something that goes along for the ride. That's not what is happening. The main thing that is happening is there is something we call sterile inflammation. These are chemicals that get released in the bloodstream when a migraine starts. The chemicals cause all the problems. The fancy medicines stop the release of those chemicals.

Ellen Beth Levitt: That's why you were saying it's important to start the treatment early when you feel a migraine coming on?

Jack Gladstein, M.D.: Exactly the less chemicals in the body, the easier it is to get the genie back in the bottle. The thing to tell parents is to think about it as toothpaste. You squeeze for a second, there is only a little mess, but squeeze it for ten minutes and your whole bathroom is a mess. If you can treat the migraine at first twinge, you have a better chance whatever you use will work. If you wait too long and be sure it's a migraine and someone is in bed with the covers over their eyes, it's harder to treat.

Ellen Beth Levitt: Do some children out grow headaches and they get older and their live becomes less stressful that they can outgrow them?

Jack Gladstein, M.D.: Some do. Most don't. The adults will flameout their migraines in their 40s and 50s.

Ellen Beth Levitt: So, if you have them a lot in your 20s and 30s, you are likely to not have them as you get older.

Jack Gladstein, M.D.: Or they might change and be easier to manage. The most important thing, if somebody has migraines young, if you can treat them really well, you might prevent someone becoming an adult pain sufferer with terrible migraines. That's why we got to get this early.

Ellen Beth Levitt: Thank you so much. It was great hearing from you on the show today. My guest has been Dr. Jack Gladstein. He's a pediatrician and director of the Pediatric Headache Clinic at the University of Maryland Hospital for Children. He's also an associate professor of pediatrics and neurology at the University of Maryland School of Medicine.

If you have any comments or questions about this program, please contact me by email at eblevitt@umm.edu.

And if you'd like to reach Dr. Gladstein or any other University of Maryland physician, call 1-800-492-5538 or visit the Web site, there you'll find a great amount of health information and be able to see other "maryland health today" programs. That address is www.umm.edu. Take good care of yourself, and we'll see you next time for "Maryland Health Today."

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This page was last updated on: December 19, 2008.

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