July 10, 2023 – Eileen Brewer is the mother of an 11-year-old who often gets severe headaches.

“She started showing signs of headache when she was a baby,” said Brewer, of Columbia, MD, where she is the president of Clusterbusters, an organization that supports research into treatments for cluster headaches and advocacy for people struggling with the condition.

Brewer’s daughter often cried for as many as 8-10 hours a day. A pediatrician said she had colic. But as she got a bit older, she began banging her head on the floor or hitting her head with her hands. The pediatrician said it was all behavioral.

But in preschool, the teacher told Brewer that her daughter was complaining about headaches on bright sunny days after outdoor play. “She would go and lie down in the book corner,” Brewer said. The teacher suggested that the little girl might be having migraines.

“I was surprised and a little embarrassed that I had missed the signs, including frequent vomiting,” Brewer said. “I myself have migraine disease, and it’s genetic. And I work in the headache space, not only at Clusterbusters, but also as the administrative manager for the Alliance for Headache Disorders. And I’m a member of the National Headache Foundation’s Patient Leadership Council.”

The pediatrician referred Brewer to several specialists, including an ear, nose, and throat doctor, a pediatric eye doctor, a dentist, and a pediatric neurologist. There were no problems with her child’s ears, sinuses, or teeth, but the eye doctor discovered a blocked tear duct as well as problems with tracking. 

“This means that when my daughter got to the end of a line of reading, finding the next line was difficult for her because the way her eyes were moving was different than the way most people’s eyes move,” Brewer said. 

Although she received physical therapy for her eyes, Brewer’s daughter continued to have headaches. The neurologist diagnosed her with chronic migraine. Now, she takes propranolol, a medication sometimes used to prevent migraine attacks, as well as sumatriptan, a medication used when a migraine attack has already begun.

‘Window to the Brain’

About 60% of children and adolescents have headaches, according to research cited by authors of a new study published in the journal Ophthalmic Epidemiology. These headaches can impact a child’s quality of life, make them less able to function well, and impact school attendance and performance.

The authors of the new study were interested in finding out how frequent eye-related problems are in children with headaches. They studied children who visited an ophthalmologist with complaints of a headache, said lead study author Lisa Lin, MD, a recent graduate of the ophthalmology residency program at Massachusetts Eye and Ear in Boston. The study was done at the Children’s Hospital of Philadelphia, where Lin attended medical school.

Lin and her colleagues reviewed the medical records of 1,878 children, ranging in age from 2 to 18, who had headache symptoms at an outpatient ophthalmology clinic. 

All children had eye exams to see if they had eye problems or other issues that may be contributing to headaches. 

The researchers found that about one-quarter of the children had one or more new eye-related findings that may have contributed to their headaches. 

Close to a fifth of the children had refractive eye issues, such as nearsightedness, farsightedness, or astigmatism.

The second most common eye condition, found in 4.4% of the children, was strabismus (eye misalignment). Very small percentages of the children had other conditions that may cause eye pain or could be a sign of an intracranial problem, including uveitis, glaucoma, and optic nerve elevation.

Patients with eye problems typically had shorter-lasting headaches, but there was no connection between eye issues and how often they had headaches, sensitivity to light, nausea/vomiting, and visual changes.

Lin acknowledges that the study was “limited” because the researchers didn’t follow the children to see if their headaches improved when the eye problem was corrected; for example, by wearing glasses. 

But the findings are important because roughly “a quarter of the children had a treatable eye condition. The eyes are often a ‘window to the brain’ and may need to be examined if children are complaining of headaches,” she said. 

Take Children’s Headaches Seriously

Paul G. Mathew, MD, an assistant professor of neurology at Harvard Medical School, said he was not surprised by the findings.

“Most children with eye problems in the study had refractive issues and probably needed glasses,” he said. 

He said that not all eye problems can be found using the standard test doctors use, and that sometimes, a more thorough eye exam is necessary. 

“I think it’s reasonable for a child to see an ophthalmologist if the child has headaches and visual complaints, but I would also caution against sending every single child with headaches to the ophthalmologist, which would drive up the cost of care and delay evaluation and treatment for children with more urgent ophthalmological issues,” Mathew said. 

Eye problems can cause headaches, but can also worsen headaches in people with disorders like migraine. He warned that a child complaining of headaches should not be ignored or dismissed. 

“I’ve noticed that parents often do not take headaches in children seriously enough, especially when they are infrequent or episodic,” said Mathew, who is on the board of directors of the National Headache Foundation. “All too often, children are told, ‘You’re just being dramatic’ or ‘you’re exaggerating.’”

Mathew, whose 11-year-old daughter has headaches, said more awareness is being brought to migraine in children. “Historically, children with migraine have been given treatments that were underwhelming, at best, but now there are more treatments being made available, and migraines in children are starting to be taken more seriously.”

He’s glad about this because “for children to have headaches that take them out of school, sports, and other activities is detrimental to their development.”

Advice to Parents 

If your child has headaches, Mathew recommends starting with a pediatrician, who can decide if the child needs further consultation with a specialist such as an eye doctor or neurologist. 

“Take nausea and vomiting seriously,” he said. “Often, children go through appropriate, extensive gastrointestinal evaluations, but these stomach symptoms can be symptoms of migraine.”

Even if the episodes don’t happen very often, Mathew feels they should not be dismissed, because they can become more frequent and intense after puberty, especially in girls. 

If your pediatrician does not take the problem seriously, Brewer advises seeking another opinion. “You know your child better than anyone else. Even if you’re a new parent, trust your gut and push for the best diagnostic efforts,” she said. “Advocate for your child, and don’t stop until you find someone who takes the symptoms seriously and has a good answer for you.”

Mathew also recommended being aware of headache triggers, such as a lack of sleep, stress, dehydration, delayed meals, and weather changes. “At this point, my daughter’s headaches are still infrequent and pretty predictable,” he said. “They tend to happen after air travel or when she’s severely sleep-deprived. So if we go on vacation, we build in plenty of downtime to make sure she gets enough rest.”

This is an important message for today’s parents, many of whom have children who are under a lot of pressure from a combination of schoolwork and extracurricular activities. “Make sure your child has plenty of downtime, eats regular nutritious meals, stays hydrated, and gets adequate sleep, and be mindful of what might trigger their attacks,” Mathew said.