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Kids Korner Archive – Exertional headaches in children

By A. David Rothner, M.D.
Director of the Pediatric Headache Clinic and Director Emeritus of Child Neurology at the Cleveland Clinic Foundation in Cleveland, Ohio

Recently, a 15-year-old boy came to the Cleveland Clinic with severe headaches that occurred while he played basketball or just afterwards. There was no accident or incident that precipitated these headaches, yet he was getting them one to three times per week. The pounding headaches were localized over his left eye and would get worse if he didn’t stop exerting himself. In fact, they got so bad that he became nauseous and vomited.

While exertional headaches like these are common in adults (some 12% of people are believed to experience them), they typically are underreported, and therefore are underdiagnosed, in children and adolescents. For young people, the vast majority of these headaches are triggered by exercise. In my practice, I see it most commonly in kids who play sports that involve intense running and exertion, such as basketball, track and football. As with adults, exertional headaches can also be initiated by other strenuous activities, such as coughing (as with the severe coughs associated with asthma and cystic fibrosis), sex and even sneezing.

Exertional headaches vary in their severity (mild to unbearable), duration (from 15 minutes to 20 hours), and symptoms (some but not all children will experience nausea, vomiting, and light and sound sensitivity, along with the pain). While the vast majority of these headaches are benign and can be prevented and/or treated, it’s important to get them evaluated to rule out any underlying cause, such as a structural lesion. This is especially true if the child experiences any neurological symptoms. For example, one young man got numbness in his hand, which traveled up his arm and to his face, before the headaches began. In his case, an MRI was normal.

Treating Exertional Headaches

For many children and adolescents, athletic pursuits are an important part of their life and self-esteem. The most important thing is, don’t tell them to stop participating in sports. Rather than stopping the exertion, prevent the headaches. I recommend taking these four steps as necessary:

  1. Avoid exertion in hot weather or at high altitudes.
  2. Hydration needs to be maintained! Drink lots of water.
  3. Two to three hours before an event that typically provokes a headache, take a therapeutic dose of a nonsteroidal anti-inflammatory (NSAID). I typically recommend naproxen at 10 mg/kilo (1 kilo equals 2.2 pounds).
  4. When a headache occurs, treat it like a migraine. This can involve bed rest, a cold compress, diphenhydramine (Benadryl®) for sedation, and an NSAID. If this regimen doesn’t prevent or relieve the headache after one or two tries, talk to your healthcare provider about the possibility of taking a triptan together with the NSAID.
  5. If the headaches are frequent and severe, occurring at practices and games, put the child on a preventive medication during the athletic season. Athletes should not take the preventive propranolol, because, by slowing the heart rate, their athletic performance will fall.

Exertional headaches are no fun for anyone of any age, and especially not for kids participating in sports and other activities. If your child is experiencing exertional headaches and not finding relief, consider making an appointment with your healthcare provider to discuss treatment options.

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