Addressing Common Comorbidities in Pediatric Headache

A multi-faceted approach is best when treating pediatric headache.

Headaches affect between 10 and 20% of school-aged children, with a steady increase in prevalence into the teen years,1 and are a major contributor to school absenteeism and reduced quality of life.2 Pain is an obvious challenge for these patients, but children with headaches also frequently have comorbid conditions that further affect quality of life and disability.

“The kids that we see in neurology often have primary headache disorders that have spun out of control – often related to comorbidities or life stressors,” Réjean Guerriero, DO, a neurology fellow at Boston Childen’s Hospital, told Neurology Advisor. “Comorbidities may include neurobehavioral or psychiatric conditions or tendencies, ranging from an anxious personality or depressed mood to clinical anxiety or depression.”  

A study published in 2012 in the International Journal of Immunopathology and Pharmacology investigated comorbidities in 280 children with primary headaches, as compared with the same number of healthy controls.3 After interviewing the children and their parents and administering psychological assessments, the researchers found that “no other psychiatric and systemic conditions are more frequent in children with primary headaches” than depression and anxiety, study co-author Piero Pavone, MD, of the department of pediatrics and pediatric emergency at the University Hospital Policlinico-Vittorio Emanuele in Catania, Italy, told Neurology Advisor. Approximately 31% of children with headaches had co-morbid depression or anxiety, compared with 8% of controls, and children with headaches showed five times the odds of having these disorders than controls.

A 2013 review from the Journal of Headache and Pain found that headache is also associated with epilepsy, attention deficit hyperactivity disorder, and Tourette syndrome, as well as atopic diseases and heart disease.Other problems that commonly occur with pediatric headaches are sleep disturbances4 and life stressors related to family, school, friends, and significant others.

“Often a combination of comorbidities may be a trigger for a headache exacerbation. These factors end up creating a downward cycle to perpetuate the headaches,” said Guerriero. For example, consider a child who is prone to headaches that is stressed about poor school performance and interpersonal problems. A couple of nights of poor sleep may trigger a headache, causing the child to become more anxious because the headache further impairs school performance – which can then exacerbate the headache and sleep disturbance, leading to an ongoing cycle that is difficult to break.

“Thus, it becomes very difficult to just treat the headache alone with medication without addressing the bigger psychosocial context in which the headache exacerbation is occurring,” said Guerriero.

Treating from All Angles

A multi-faceted approach may be needed that emphasizes helping the child live as normal a life as possible, including no absences from school and continuing to spend time with friends or engage in activities they enjoy. Additionally, staying well-hydrated, maintaining a consistent sleep schedule and healthy sleep hygiene (like a no-electronics rule after a certain time of day), and regular physical exercise can be helpful.

Findings reported in Cephalalgia in May 2015 show that children who liked to play sports in their free time had significantly lower PedMIDAS scores than children who did not like playing sports.5

Guerriero suggests that more soothing types of exercise, such as yoga, walking, and dancing, can also confer benefits.  

“Lastly, addressing the behavioral or psychiatric conditions are key,” said Guerriero. “Cognitive behavioral therapy (CBT) is the most well-proven to help kids with chronic headaches, pain, somatic symptoms, and anxiety.” It may also be important to involve a school guidance counselor if academic plans or goals need to be addressed.  

Of course, medication may have a valuable role in managing chronic headaches in some patients. “Drugs used in symptomatic treatment should be chosen carefully according to headache type, frequency, type of symptoms, and adverse-effect profile,” said Pavone. “It is advisable to include comorbidities in the choice, such as depression and insomnia, which a tricyclic antidepressant helps to control along with migraine.” For chronic headaches, a low dosage of a daily medication may help, and melatonin may be used as a gentle sleep aid, Guerriero said.

The more adept pediatric headache patients and their parents become at recognizing the child’s headache triggers, the better they will be able to manage them. Parents should refrain from constantly asking their child about their headaches, “but rather observing the child’s behavior to assess how they are doing can be really valuable at shifting the focus away from the headache itself,” said Guerriero. “Distraction can be a valuable treatment as well!”


  1. Bellini B, Arruda M, Cescut A, et al. Headache and comorbidity in children and adolescents. The Journal of Headache and Pain; 2013; 24;14:79.
  2. Antonaci F, Voiticovschi-Iosob C, Di Stefano A, et al. The evolution of headache from childhood to adulthood: a review of the literature. Journal of Headache and Pain; 2014; 15(1): 15.
  3. Pavone P, Rizzo R, Conti I, et al. Primary headaches in children: clinical findings on the association with other conditions. International Journal of Immunopathology and Pharmacology; 2012; 25(4):1083-91.
  4. Guidetti V, Dosi C, Bruni O. The relationship between sleep and headache in children: implications for treatment. Cephalalgia; 2014; 34(10):767-76.
  5. Bektaş Ö, Uğur C, Gençtürk ZB, et al.  Relationship of childhood headaches with preferences in leisure time activities, depression, anxiety and eating habits: A population-based, cross-sectional study. Cephalalgia; 2015; 35(6):527-37.