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State-of-the-Art Pediatrics

October 2018

Promoting Function with Chronic Headaches

Author: Klanci M. McCabe, PhD | Developmental & Behavioral Medicine | Clinical Assistant Professor of Pediatrics, UMKC School of Medicine

Column editor: Amita R. Amonker, MD | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine

Individuals with chronic headaches tend to have difficulties keeping up with usual activities, such as school. For many, bright lights, loud noises, smells in the cafeteria, crowded hallways and academic pressures all can exacerbate their headache presentation. The initial and natural instinct often is to avoid environments that are perceived to make the headaches worse. However, doing so can actually promote greater disability and future absenteeism. Avoidance tends to be rewarding in the short term, as it limits the exposure to the factors that make the symptoms worse, thus increasing comfort. However, as avoidance becomes a repeated response to pain, it leads to getting behind in schoolwork, not seeing friends, being less active during the day, mood changes, sleep changes and feeling overwhelmed.1 Repeated avoidance of the school environment as a response to headaches also can result in lower graduation rates and poorer occupational and health outcomes later in life, 2,3 and can establish adversarial relationships with schools which depend on full student attendance, at least in part, for accreditation and funding.

Absences from school also reduce opportunities for a powerful pain-coping skill: distraction. Headache pain is partially processed through activating the anterior cingulate gyrus in the frontal lobe, which regulates attention and motivation. Engaging in the social and mental tasks associated with school provides a competing response that can reduce pain perception. Attending school, setting goals and having a purpose each day also promotes being more future-oriented, and improves hopefulness. Just the simple act of getting up and moving to participate in the regularly scheduled school day also can help reinforce continued positive coping and mood improvement through a concept called behavioral activation.4

Thus, coming up with strategies that help promote continued involvement in school and other activities is a critical component of comprehensive headache management plans. Rather than encouraging removal from school through advocating medical homebound, a preferred approach is to establish accommodations for the student to address their headache symptoms while remaining at school. Some example accommodations for chronic headaches include access to water/snacks, preferential seating, opportunities for breaks in a quiet/dimly lit room, reduced computer exposure, flexibility with attendance policies, limiting assignments to essential learning tasks, and providing extensions for make-up work. With specific accommodations in place, individuals are better able to manage their symptoms and attend school consistently. In turn, school attendance, despite having chronic headaches, combats chronic absenteeism and leads to better long-term outcomes for youth with this condition. 

For additional resources, visit http://www.headachereliefguide.com.  This site includes a medical provider portal to create an evidence-based headache action plan, receive customize medication recommendations, school letters for 504 plans, as well as healthy lifestyle handouts and headache calendars for your patients to use. It also provides other interactive learning resources to help educate patients and  their families about headaches.


References:

  1. Pediatric Fear-avoidance Model of Chronic Pain: Foundation, Application and Future Directions. Asmundson G, Noel M, Petter M, Parkerson H. (2012). Pain and Research Management: 17 (6): 397-405.

  2. https://www2.ed.gov/datastory/chronicabsenteeism.html.

  3. https://healthyschoolscampaign.org/wp-content/uploads/2017/02/Addressing_Health-Related_Chronic_Absenteeism_Toolkit_for_Action_Full.pdf.

  4. Chronic Pain in Children and Adolescents. Eccleston C, Carter B. (2006). Paediatric Nursing. Dec; 18 (10): 30-3.