A child says their head hurts, and the family's first move is usually the same: get the eyes tested.
Sometimes that is right. Far more often the eye test comes back normal, glasses are prescribed anyway, the headaches continue, and a year passes before anyone asks the questions that would have found the answer in twenty minutes.
Headache is common in childhood. By the teenage years the majority of children have had one, and a meaningful minority get them regularly enough to miss school. Most have a cause that is entirely manageable. A small number do not — and knowing which is which is the whole point of this article.
Migraine in children looks different
This is the single most useful thing for a parent to know, because childhood migraine is frequently missed for exactly this reason.
In children, migraine is often on both sides of the head, not one. It is often shorter — sometimes just an hour or two, where an adult attack runs half a day. And in young children, the stomach can dominate: the child complains of tummy pain and nausea, vomits, goes pale, wants to lie down in the dark, sleeps, and wakes up well.
Families describe this as "he keeps getting stomach upsets" for years before anyone recognises it.
Look for the pattern rather than the location. A child who repeatedly becomes pale, wants darkness and quiet, vomits, sleeps, and then is completely fine — that pattern is migraine until proved otherwise, whichever part of the body they point to.
Family history helps. If a parent has migraine, the odds go up considerably.
Tension-type headache
A pressing, band-like ache across the forehead or both sides, usually mild to moderate, without vomiting, and not made worse by running about.
In school-age children the usual drivers are dull and real: not enough sleep, skipped breakfast, dehydration through a hot day, long screen hours, heavy school bags, poor posture at a desk built for an adult, and exam stress.
These headaches respond to fixing the cause far better than to medication.
What is usually blamed, and what is usually true
Eyes. Refractive error can cause headache, but it is a less common cause than most families assume. Get the eyes checked once. If the test is normal, stop returning to the eye specialist and look elsewhere.
Sinus. Genuine sinus headache comes with a blocked nose, discoloured discharge and facial tenderness, during an infection. Chronic recurrent "sinus headache" in a child with a clear nose is usually migraine.
Gas or acidity. A very common label in Indian households for what is often abdominal migraine.
Screens. Long unbroken screen time is a real trigger, particularly through late-night phone use. But screens are usually one contributor among several, not the whole answer.
Dehydration and skipped meals. Underestimated, and among the easiest to fix. A child who leaves for school at 7 without breakfast and drinks little all day has two triggers before lunch.
Warning signs — see a doctor promptly
Most childhood headaches are not dangerous. These are the exceptions, and they change the urgency.
- Headache that wakes the child from sleep, or is present on waking most mornings
- Headache with vomiting in the early morning, especially if it eases afterwards
- Headache that is clearly worsening week by week rather than staying the same
- Headache made worse by coughing, straining or bending forward
- Any weakness, numbness, unsteadiness or change in walking
- Double vision, blurred vision, or a squint that is new
- Seizures
- A change in behaviour, personality or school performance alongside headaches
- Head circumference growing too fast in a young child
- Headache in a child under five, who is too young to be getting typical tension headaches
- Sudden, severe headache reaching maximum intensity within seconds — this is an emergency
- Headache with fever and a stiff neck — this is an emergency
The combination that concerns doctors most is a morning headache with vomiting that improves after vomiting, getting worse over weeks. Individually each is common; together and progressive, they need imaging.
Does my child need an MRI?
Usually not — and pushing for one when it is not indicated has costs.
Migraine and tension headache are diagnosed from the history and the examination. There is no scan that shows migraine. A normal scan does not exclude it, and an abnormal incidental finding causes years of worry without changing treatment.
What actually makes the diagnosis is a careful history — when it started, where it sits, how long it lasts, what makes it better and worse, what else happens with it, how many days a month, how much school is missed, what medication is taken and how often — plus a neurological examination including looking at the back of the eyes.
That last part matters. Examining the optic disc shows whether pressure inside the head is raised, and it takes a minute. If your child has had recurring headaches and nobody has looked into their eyes with an ophthalmoscope, the examination was incomplete.
Imaging is indicated when there are warning signs, an abnormal examination, a headache pattern that has clearly changed, or a child under five with persistent headaches.
The medicine trap
This one causes more chronic daily headache in teenagers than parents realise.
Painkillers taken frequently — more than about two days a week over months — can themselves cause a daily headache. The child takes a tablet, feels better briefly, the headache returns, they take another. The treatment becomes the cause.
If your teenager keeps painkillers in their school bag and uses them most weeks, that is worth raising at the appointment. It is entirely reversible, but it needs a planned withdrawal, not just stopping abruptly.
Take medication early and at the right dose when an attack starts, and count the days per month. Fewer than four days a month is fine. More than eight is a conversation.
The headache diary
Ask your child's doctor for one, or just use a notebook. For each headache, record:
date · time it started · how long it lasted · how bad, out of 10 · what else happened (vomiting, light sensitivity) · what medicine, and did it help · school missed · anything unusual that day, including sleep and meals
Two months of this is worth more than any test. Patterns nobody expected turn up — headaches clustering before exams, on days with no breakfast, after late nights, around menstrual periods in teenage girls.
What usually helps
Sleep, at consistent times. The most effective single change in most children. Same wake time on weekends too.
Breakfast, without exception, and a water bottle at school.
Screen breaks, and phones out of the bedroom at night.
School bag weight, desk and chair height, and where the screen sits for homework.
Named stress. Exam pressure, bullying, difficulty in one subject, trouble at home. Children rarely volunteer these, and headache is sometimes how it shows.
Treating attacks properly. Early, adequate dose, rest in a dark quiet room if it is migraine. Undertreating an attack and then taking repeated small doses is worse than one proper dose at the start.
Where attacks are frequent and disabling despite all this, preventive treatment exists and works. That is a conversation with a paediatrician or neurologist — see our guide on which specialist your child actually needs.
What to bring to the appointment
The diary. Every medicine tried, with doses and whether it helped. How many school days have been missed. Any family history of migraine. Any previous eye test or scan reports.
And let the child speak. Children describe their own headaches better than adults expect, and the description is where the diagnosis lives.
Written by Dr. P. K. Jha, MBBS, MS, MNAMS, M.Ch (Neurosurgery, AIIMS New Delhi), DMC Reg 13809. Consultant Neurosurgeon with over 30 years treating brain and spine patients. Practising at Neuro Care India, Gaur City 1, Greater Noida.
This article is educational and is not a substitute for a clinical consultation. A sudden severe headache, or headache with fever and a stiff neck, needs emergency assessment.