As kids return to school and schedules full of sports, clubs, and other extracurricular activities, some must contend with an unfortunate byproduct of their hectic schedules: headaches.
Pediatric headaches spike in autumn as kids' stress goes up and the quality of their sleep declines. Parents may wonder whether it's time to grab the Tylenol or call the doctor. Pediatric neurologist Hannah Shapiro , MD, a headache specialist in UCSF's Child and Adolescent Headache Program directs the UCSF Benioff Children's Hospitals' Pediatric Headache Clinic in Walnut Creek and conducts research on treatment.
Currently, she is working with 13 other sites around the U.S. to examine how well virtual cognitive behavioral therapy (CBT) works for children with migraine.
What is CBT?
It's a skills-based intervention meant to decrease head pain in the moment and over time, as the person learns behavioral strategies developed by clinicians. The strategies are tailored to the individual, but may include biofeedback and relaxation training, as well as practical tactics like taking breaks during the school day and while doing schoolwork.
What questions are you asking about CBT?
We know from past research that children with migraine who take medicine and do CBT fare better than those who just take medicine. Now, we are trying to discern if CBT works as well alone as with medication.
Also, the CBT in the study is virtual, so a second goal of the study is looking at the feasibility of doing CBT remotely for headache.
How might the results of this study change treatment?
If we find that CBT could be used alone as a first-line treatment, I think a lot of parents would be interested; they often hesitate to put their children on medication at a young age.
How common are headaches in children?
About 60% of children experience significant headaches; it's very common to have headaches as part of growing up. Adolescents have them more than younger children, and girls start to outpace boys during puberty.
How are headaches different for kids versus adults?
First of all, young children may have a hard time describing the symptoms of their headaches, so we must infer from their behaviors. For example, they may not tell you that light or sound bothers them during a headache, but they will ask to turn off lights or turn down the T.V. Also, migraines in particular can be pretty different. For adults, the pain is usually on one side of the head and lasts at least four hours. In children, the pain is more often on both sides of the head and can be as short as two hours.
How can parents help prevent or mitigate headaches in their kids?
Some common headache triggers include dehydration, lack of sleep, stress, and skipped meals. Make sure your kids shift their sleep schedule a week before school starts so they will get enough sleep - and keep the same sleep schedule on weekends. Send your kids to school with a water bottle so they stay hydrated, and check that they eat breakfast and lunch. Be sure they take time to relax and have coping strategies for stress, such as listening to music, hanging out with friends, drawing, sports - whatever works for them.
If your child tells you they have a headache, how can you tell if it's serious?
Most headaches in children are not dangerous. If the headaches are new, mild, and infrequent - and they respond to over-the-counter medications - it's usually fine to treat at home.
If the headache is new and intense, let their doctor know. If your child has a recurring headache that is increasing in frequency, duration, or pain level, or it is happening in a different part of the head than usual, let the doctor know.
What sort of headache might indicate a trip to the emergency department?
One is a thunderclap headache - where someone feels fine and then suddenly it's the worst headache of their life. Another is a headache accompanied by vomiting that won't stop, especially if the vomiting is overnight or first thing in the morning.
Why might a child be referred to UCSF's Child and Adolescent Headache Program?
If there is any uncertainty around the diagnosis, or if a child has tried the standard first-line treatment and didn't respond, they would be referred to us. Another reason might be that the headache is causing a lot of functional disability, like missing school or sports activities.
UCSF's program has four pediatric neurologists with specialized training in headache, which is three to four more specialists than most facilities. We also have clinics in four locations: San Francisco, Oakland, Walnut Creek, and Los Gatos.
What happens when a child first comes to UCSF's program?
The doctor will take a detailed headache history and provide a diagnosis. Every patient receives a comprehensive headache management plan. First, we talk about lifestyle changes to mitigate headaches. We also offer Cognitive Behavioral Therapy, or CBT, with one of our headache psychologists to reduce the frequency and severity of the headache.
Next, we look at a prevention plan, which addresses how the patient can keep headaches from happening, such as taking a supplement or prescription medication, or using a neuromodulation device. Everyone also gets an acute plan, which guides what the person should do once they feel a headache coming on, such as taking a particular combination of as-needed medications. And we offer various procedures in the clinic as needed, as well as infusions in the outpatient and inpatient settings.
What kind of procedures and infusions do you offer?
For procedures, one is an occipital nerve block, which entails giving an injection in the back of the head to disrupt a bad headache cycle. We also do Botox for chronic migraines as preventive therapy; it works by tracking back through the nerves that carry pain messages to turn off pain signals in the brain. And we have an outpatient infusion program, where a child receives intravenous medication that goes directly into the blood, so it works faster and is more potent than medicine taken orally.
If the headaches are severe and intractable, we also may admit the child to the hospital and do around-the-clock intravenous therapy for four to five days with different medications. The goal is to dampen down the headache pattern.
How do neuromodulation devices work?
These devices, which patients use at home, are a way to modulate pain processing in the brain without using medication. There are different versions. With remote electrical neuromodulation, the patient wears a band, usually on the arm, to stimulate sensory and pain fibers. This sends signals to the brain that compete with pain signaling.
Another device is a noninvasive vagus nerve stimulator that the patient puts on the neck. It activates the vagus nerve to disrupt some of the pain signaling. Both devices can be used either in the moment or as a preventive treatment. And both are great because they are safe, non-medication ways to treat headache without medications.
What is the newest headache treatment you offer?
At the Walnut Creek clinic, we launched an outpatient headache infusion program in late 2024. There, we offer appointments within a couple days for IV therapy, so that patients with severe headache flares don't have to go to the emergency department (ED). We take care of insurance in advance; a headache doctor picks the medications that best fit the patient's treatment plan; and the patient can come in for just two hours of treatment and go home. Of course, this option is only for patients we know aren't having some other issue that requires an immediate visit to the ED.
So, the patients are ok with postponing care, even when in intense pain?
We find that patients prefer to wait it out at home and use their oral medications until they can have an appointment in the infusion center where it's a much more comfortable experience than the ED. People with headache disorders have a lot of sensitivity to light and sounds, and there are a lot of those triggers in an ED. Plus, they usually end up being triaged to a lower priority, so they wait a very long time to be seen.
