many years ago i volunteered to perform sports physicals at four local middle schools. i spent a lot of time in that nurse’s office and apparently so did many of the students. all day long it was a dance of complaints. since the nurse’s professional hands are often tied when it comes to treatment the most common disposition for a sick child is a trip home. next to tummy aches headaches were at the top of the whine list. when i think back to my own middle school days there were plenty of things that can lead to headaches. just being at school all day is a headache to some kids. fortunately for all of us most headaches are not brain tumors or aneurysms. in healthy active kids the most common type of headache that is seen is the classic muscle-tension headache. the brain itself does not feel pain but all of the sensitive nerves muscles and blood vessels of our head can certainly generate a doozie of a headache. don’t get me wrong; headaches can be hallmarks of something more serious but most of the time a random self-limiting headache is just that… a headache. headaches are in the body of the beholder. a medical provider cannot see a headache which makes this an ideal get-out-of-school reason. teenagers tend to be great actors and are able to give a command performance at will. some performances are so good they end up in my office. by the time i see them parents are worried about brain tumors meningitis and all types of horrible diagnoses. “on a one to 10 scale with 10 being the worst headache what number do you give your headache? ” if a comfortable-looking person tells me “nine ” and their mannerism looks more like a one or two i am suspicious. i will then inquire as to the frequency of headaches their location on the head factors that may bring on the headache and things the person does to make the headache better. the number of missed days from school is another important bit of information. “i think it’s a migraine. ” most people don’t have a clue what “migraine” really means but will frequently self-diagnose. most feel that the word “migraine” just indicates a bad headache. when i explain to them that a migraine is a certain type of vascular (blood vessel) headache that usually occurs on just one side of the head usually severe accompanied by nausea/vomiting and proceeded by an “aura” (a feeling that a headache is imminent such as blurry/wavy vision) they will usually admit they do not have these things. migraines tend to run in families and in women may be cyclic related to menstruation. among many other triggers hormonal contraceptives can also trigger migraines in some people. younger children do a lot behavioral modeling. they see a parent constantly complaining of headaches and they may get one too. headaches located at the back of the neck or upper shoulders radiating to the scalp and feeling like your head is in a vise are usually muscle tension headaches. these can be due to sleeping on several thick pillows (flexing the neck) or sitting like a slug in those uncomfortable school desks. nervous tension like algebra tests or the day they need to run a mile in physical education all can create tension headaches. on examination i can usually find a very sore area (trigger point) around the nape of the neck and of course no clinical findings suggestive of brain tumors. parents are relieved; students not so much. sorting out real headaches from just headache complaints used to avoid something requires a lot of skill and experience. kids will get headaches when they are worried. tension at home like parents arguing or families going through a divorce will trigger headaches in kids. a physically or emotionally abusive parent will trigger headaches. bullying at school is another factor. when children are being teased or intimidated by other classmates they may use headaches as an excuse to go home. teachers can be bullies too. when i recall my elementary and middle school days there were some very unfriendly teachers in my life. teachers should always be respected but never feared. in dissecting factors that may be triggering a headache overly demanding (mean) teachers are often high on that list. rather than just prescribe tylenol or motrin it behooves the clinician and the parent to get more information. real headaches exist. serious headaches exist. even those pseudo-headaches deserve our utmost attention.
when is a headache a real problem?