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What Are the Different Types of Headaches?

In the pediatric age group, “headaches” is a relatively common complaint and most of the headaches will not require any neurological consultation. In the very young, one must distinguish true headaches from an incorrectly used “headache” term. Some children may use the word headaches to express toothache, fatigue, or dizziness. When evaluating headaches, one must take into consideration the duration of the complaint (when did it first start), the severity, and the specific features of the complaint. One must distinguish painful headaches from harmful headaches. In the U.S., 10% of children under 15 years of age have migraine headaches and about 1% have chronic tension headaches.

The different types of headaches include the following:

Migraine headaches

Migraine headaches occur in about 10% of children and exhibit specific features (see migraine section). These features sometimes overlap with tension headaches, presenting as “mixed type headaches,” mostly with migrainous characteristics.

Chronic tension headaches

These headaches are mostly bilateral (both sides) and diffuse. The pain is dull and fluctuating, usually not worsened by physical activity (unlike migraines). This headache may occur on a daily basis with relatively short intervals of being headache free. These children may be using a large quantity of painkillers. This causes them to have withdrawal headaches as the medicine comes out of their system and the pain then rebounds.

The treatment of these headaches is difficult and requires the discontinuation of frequent use of over-the-counter medications. Preventative (prophylactic) treatment may include Pamelor (nortriptyline) or Elavil (amitryptylin), which are tricyclic antidepressants with an excellent pain control quality. Another advantage of these medications is that they may improve sleep and control the depressed mood sometimes associated with chronic headaches.

Withdrawal headaches

These include caffeine withdrawal or medication withdrawal (mostly Tylenol, Motrim, or other pain killers containing caffeine, such as Excedrin). These headaches are cyclical and respond promptly to caffeine medications but reappear a few hours later when the substance is out of the system.

Treatment of these headaches may be complicated, since the body is “addicted” to a substance and may require hospitalization.

“Allergic” headaches

One may develop headaches from exposure to any substance such as fumes or different smells of food. Some foods may cause headaches but may also trigger true migraines. The medical literature reports that about 17% of children have some relation between food and their headaches. My personal experience is that this number should be higher (about 30%). Foods known to trigger headaches or migraines include: nitrates (hot dogs, bologna, bacon, salami); chocolate; monosodium glutamate (MSG) such as in Chinese food; nuts and peanuts; some fruits such as strawberries, bananas, and orange juice (including other citrus); and caffeine. Also, any kind of prescription or nonprescription medication may cause headaches.

Episodic tension headaches

These are very common headaches in all age groups and are associated with the stresses of life. Fatigue, stress, oversleep, or exertion may trigger these headaches. These headaches will not have migrainous characteristics (nausea, vomiting, fatigue, sensitivity to light). The treatment is with over-the-counter analgesics and removal of the stress.

Exertion (exercised induced) headaches

These are very characteristic headaches. They start fast and strongly (like a thunderclap) and resolve rapidly. They are always related to an acute, rapid, strong exertion such as starting to exercise. These headaches respond readily to treatment with Indocin ( a strong anti-inflammatory medication that penetrates into the brain when given before the exertion). My experience, however, is that many children with this type of headache respond to milder anti-inflammatory medications such as ibuprofen when given one hour before exertion.

Cluster headaches

These are severe acute headaches that are extremely rare in children and occur mostly in men who smoke. The cluster usually consists of daily headaches for one to two months, most often in the spring and fall. The pain may last one hour behind one eye and is excruciating. This may repeat two to six times per day and the patients can’t sit still. This pain may respond to oxygen, given by mask, or to Imitrex. Prevention with prednisone, lithium, calcium channel blockers, or methysergide may be helpful.

Eyestrain headaches

Eyestrain is commonly blamed for causing headaches but is rarely a true cause. If eyestrain is the cause, resting the eyes should resolve the headaches. It is related to ocular near fixation rather than refractive errors.

Headaches Caused by Other Medical Conditions

Brain tumors

A brain tumor is a major concern that brings children to the neurologist for an evaluation. Brain tumors are a very rare cause for headaches and many brain tumors do not present with headaches. Headaches related to a brain tumor will be caused by increased intracranial pressure and will present with certain characteristics. These include a gradual worsening over the course of time and pain mostly in the morning hours that may be associated with nausea or vomiting and may resolve towards the afternoon hours. One must remember, however, that different presentations may be possible. As a rule, by the time the vast majority of tumors will cause a headache, there are going to be some abnormalities on physical examination.


This is a “scary” condition in the pediatric age group. If caused by bacteria, it must be promptly diagnosed and treated. Fortunately, there are clear clinical signs that help us identify it (fever, stiff neck, lethargy, vomiting) but early on these may be missed.

Other infections

Encephalitis, viral meningitis, or any other bacterial or nonbacterial infections that cause fever, even when not involving the central nervous system, may cause headaches (e.g. bad cold). The specific source of infection must be identified and treated.


Sinusitis (like eye strain) is very commonly implicated in causing headaches even when this is not the case. Many children with migraines or tension type headaches end up on one or more courses of antibiotics before arriving for a headache consultation. Sinusitis obviously should not be missed but it must be appropriately evaluated. Sinusitis headaches are worst when bending down and are associated with pain or pressure over the sinuses. They may be diagnosed with a sinus film or cat scan. Frequently, there will be a greenish nasal discharge with sinusitis.

Posttraumatic headaches

Following a severe head trauma with a concussion, an individual may develop chronic headaches that resolve gradually, but on some occasions they will persist. Other symptoms of a “post concussion syndrome” will include sleeping difficulties, learning problems, short attention span, irritability, and personality changes.

Temporomandibular joint syndrome (TMJ)

TMJ is more common in adolescents and it is caused by impairment inflammation of the joint that connects the jaw to the skull. Chewing induces the pain which may then radiate to the ear and upwards. The pain may be severe at times and radiate to the rest of the skull or the same side. Treatment is provided by a night stabilizer of the joint (teeth brace) and by oral surgery. Anti-inflammatories may be helpful. The most accurate diagnosis of this condition is clinical and by an MRI of the temporomandibular joint.

Whiplash and other neck injuries

Whiplash and other neck injuries may cause a chronic occipital headache.

Seizure headaches

Children with seizures may have headaches following a seizure attack. On rare occasions, the seizures are unidentified and the presentation is with headaches alone.

Migraine Headaches

Migraine headaches are common in the pediatric age group. About 10% of children 5 to 15 years of age, occasionally even earlier, will develop migraine headaches. After adolescence, about 6% of men and 18% of women will develop migraines. About 75% of the visits to the pediatric neurologist due to “headaches” turn out to be migraines. The diagnosis of migraine headaches is clinical. The diagnostic criteria were most recently re-established by the International Headache Society (IHS) in 1988. These criteria state that migraines must be chronic headaches with recurrent episodic attacks (a constant headache is not a migraine). There may or may not be an aura (a visual change that occurs prior to the headache and may serve as a warning sign that the migraine is imminent). This distinguishes the two migraine types:

  1. Migraine with an aura (formally classic migraine)
  2. Migraine without an aura (formally common migraine)

The duration of a migraine must be over 4 hours, but in children may be shorter. Also migrainous characteristics must be present. These may include fatigue. Sleep may be helpful and the child must feel tired, yet in many children there may be some associated difficulties with sleeping despite the tiredness (due to the pain). Other migrainous features may include nausea, vomiting, sensitivity to light and noise (phonophotophobia), and some associated dizziness. The frequency of the migraines may be rare, 1 to 2 per year, or may be frequent, several times per week.

Triggers for the migraine attacks must be identified due to the ability to prevent attacks by changing some environmental exposures. Triggers may include certain foods, such as chocolate, caffeine, Chinese food (MSG), nitrates (hot dogs, bologna, ham), yellow cheeses (cheddar, dark, or hard cheeses), nuts and peanuts, strawberries, bananas, or orange juice and other citruses. Not all foods are responsible for the headaches but some may be. Other triggers may be stress, fatigue, over sleeping, noises, smells, minor head bumps, bright lights, or physical activity.

Treatment for Migraine Headaches

The treatment of migraines must be divided into two main considerations.

  1. Treatment that stops acute attacks (abortive treatment)
  2. Treatment that prevents the headaches from happening in the first place (prophylactic)

The preventative treatment may be achieved by medical and nonmedical measures. The termination of an acute attack is achieved with the use of medications. Many different medications may be effective. Some may be given orally, intranasally, and by injections.

This is the list of medications used to terminate acute attacks:

  1. Triptans:
    • Naratriptan
    • Rizatriptan
    • Sumatriptan (Imitrex)
    • Zolmitriptan (Zomig)
    • Eletriptan
    • Frovatriptan
  2. DHE (dehhydoergotamine) with or without antiemetics
  3. Combination medications:
    • Furinol
    • Furicet
    • EsgicPlus
    • Midrin
    • Aspirin
    • Butorphenol
    • Ibuprofen (Motrin)
    • Naproxen
    • Prochlorpemazine (Phenergan)
    • Metoclopramide
    • Excedrin
    • Tylenol number 2
    • Chlorpromazine
    • Diclofenac (Volteren)
    • Ketoralac (Toradol)
    • Ergotamine with or without caffeine
    • Lidocaine
    • Meperidine
    • Methadone
    • Acetaminophen (Tylenol)
    • Dexamethesone
    • Hydrocortisone

Preventative treatments should be considered if the migraines become frequent, causing a significant impairment in function or lifestyle or causing paralysis (this may lead to stroke).

Preventative treatments may include the following:

Other unproven nonmedical methods for the treatment of migraines include the following:


Medications used for the prevention of migraine attacks (prophylaxis) include the following:

  1. Beta-blockers:
    • Propanelol (Inderol)
    • Timolal
    • Nadolal
    • Metoprolol
    • Atenolol
  2. Antidepressants (tricyclics):
    • Amitriptyline (Elavil)
    • Nortriptyline (Pamelor)
    • Doxepin
    • Imipramine
    • Protryptyline
  3. Antidepressants (SSRI):
    • Fluoxetine (Prozac)
    • Paroxetine (Paxil)
    • Sertraline (Zoloft)
    • Fluxaminie (Luvox)
  4. Monoannine oxidase inhibitors (Phenelzine)
  5. Other antidepressants:
    • Bupropion
    • Trazodone
    • Venlafaxine
  6. Antiepileptics:
    • Valporic acid (Depakote)
    • Carbamazepine (Tegretol)
    • Gabapentin (Neurontin)
    • Topiramate (Topamax)
    • Tiagabine (Gabitril)
  7. NSAIDs:
    • Aspirin
    • Ibuprofen
    • Naproxen
    • Other NSAIDs
  8. Serotonin antagonists:
    • Cyproheptadine (Periactin)
    • Methysergide
  9. Calcium channel blockers:
    • Nimodipine
    • Verapamil
    • Diltiazem
  10. Others:
    • Magnesium
    • Vitamin B2
  11. Other medications:
    • Many other medications, including some not scientifically proven to have a benefit, have been tried with a various rate of success.

The choice of preventative medications is made based on other needs of the patient, including sleep or eating difficulties, depressed mood, difficulties concentrating at school, and other considerations. The best situation is to benefit the child in more than one way with the choice of the therapeutic agent.