Managing Headaches & School

How common are headaches in school age children?

Headaches during the school year can create difficult problems for students, parents, and teachers. Concerns may include how to manage a severe headache at school, relate to peers, cope with homework when it hurts to read, and even whether to attend school or not. Fears of failure or falling behind can emerge when headaches become more frequent or severe. Parents may struggle with whether they should push their children or excuse them from activities. Teachers and administrators may question how to respond and what to reasonably expect in school performance.

Migraine affects 2%-5% of children below the age of 12 and increases to 10% by late adolescence. The percentage of children with frequent or severe headache rises from 1% below the age of 10 to 5% between the ages of 10-17. Headaches sufficient to cause functional impairment affect about 1 out of 10 children between the ages of 9-18.

Headache can affect how well a child does in school. About 37% of children with migraine note poor school performance during headache. Most identify difficulty concentrating in class and on homework. One pediatric practice identified school problems in 46% of their adolescent headache patients. Another recent study found that young headache patients rank "school" among their most potent headache triggers - ahead of "parents" and other common triggers such as weather, lack of sleep, or missed meals. School-related noise and bright lights emerge as a consistent problem for the headache-prone student. Peer problems such as frequent bullying or harassment are also associated with more frequent and severe headaches.

In the 1989 National Health Interview Survey, headache ranked third as a cause of school absence, accounting for over 82,000 days of missed school per week. Children with frequent or severe headaches miss an average of 3.6 school days per year per child. However, about 10% of young people with migraine miss over 2 school days per month, and roughly 1% miss 2 days per week. Children between the ages of 7-17 with chronic daily headache who were treated in a pediatric specialty practice missed an average of 6.3 days per month, or about 57 days over the school year.

When school absences escalate, school attendance and performance can cause as much distress as the headache itself. The student may begin avoiding school or homework due to pain; absences and incomplete assignments increase; the student falls farther behind; peers start asking questions or teasing the student; teachers question the legitimacy of the headaches; and schools may pressure a student about the number of absences. The student may come to believe, "If I have trouble with studying or going to school with a headache, why go at all?" and stop attending. Parents may find themselves in conflict with each other or the school.

In such cases, effective treatment must focus on two areas at the same time:
1) headache control;
2) a plan to manage school-related issues.

How should headaches be handled in the school setting?

For headaches severe enough to interfere with functioning, it is crucial that parents, student, health care providers, and school personnel communicate with each other, and agree on a plan for managing severe headaches. The treating physician should provide the school with a clear diagnosis and a practical headache management plan. If medication is required during the school day, the school needs to understand this as well as the limits on frequency of drug use. Overuse of certain pain medications can lead to analgesic rebound headaches, where headaches increase in frequency and severity as the patient becomes dependent on the drug. Drug use should be closely monitored by parents. In turn, parents need to understand the school's medication policy so they can advocate for their child while working within the system. If possible, a quiet location for relaxation and a brief break from class may help keep the child in school and allow a return to the classroom when the pain is under control.

Should children attend school with severe headaches?

Most headache specialists believe it is important for a young person with frequent headaches to stay in school, normalize activity, and learn to function in the presence of pain even if the pain is severe. Research reveals that the more emotional distress a parent shows to a child in pain, the more upset the child becomes. Compassionate acknowledgment of the pain can be combined with calm but firm expectations about schoolwork and attendance.

The normal parental instinct is to comfort a child in pain. It may seem cruel to force a child to study or attend school with a severe headache. However, students who continue to attend despite the headache learn to conquer headache-related fears, overcome personal obstacles, maintain involvement with their peers, develop a "can do" attitude, and earn the respect of others and themselves. In contrast, students who primarily avoid activities due to pain can become increasingly isolated, depressed, and see themselves as failures.

When attendance and school performance suffer due to frequent, severe headaches, ongoing treatment with a specialist in headache-related behavior should be part of the overall management plan, with an emphasis on developing a return to school plan. In some cases, selecting 1 or 2 classes that the student will consistently attend every day, even when in pain, can serve as a foundation for gradually increasing school involvement.