Headache in a 5-year-old

Molly, 5, had an eye problem. It was pretty common, and her eye doctor recommended that she wear a patch on one eye several hours a day. She didn’t mind this, and she and her parents picked out all different designs for the patch that might suit her mood or fashion requirement. Usually, the patch is worn over the stronger eye in order to force the weaker one to get more exercise. 

So when her mother told me that she had a headache, my first guess was eyestrain. It's a common cause of headache at almost any age. But still, 5-year-olds don't often complain of headaches.

Her mother was sympathetic. She told her child that she'd get some medicine for her that would help her feel better, and went to the cabinet where they keep the acetaminophen. It was only a few steps away, but Molly started crying. She said that it was still hurting. Mother repeated that she would give her some medicine that would help. Molly said that it wouldn't help. Mother said, calmly, that she thought it would and that after the medicine they would lie down in the bedroom together until she felt better. Molly said that it wouldn't help and that it was going to get worse and it was getting worse right now and she didn't know what was going to happen and that it was still getting worse and medicine isn't going to help and nothing is going to help and she was really scared. Molly was screaming by now, continuing to express her fear and pain. Mom had picked her up, of course, and was doing her best to settle her.
She did the best thing she could think of, and took her into the bedroom. They lay on the bed together, with Molly in her mother's arms. Soon, Molly fell asleep and was better a few hours later when she awoke. When mom told me the rest of the story, I told her I wanted them to come to the office so I could speak to Molly in person.
Fortunately, Molly is smart and talkative and likes me as much as I adore her. She told me that her eyes didn't hurt when this happened. Her mother told me that there really wasn't a family history of migraine.
Though in my training I received a little exposure to migraines, even now this is generally thought to be uncommon in children. I have a feeling that isn't right. I have diagnosed migraine in children as young as 5, and there is often a family history. Their symptoms are usually just like adult symptoms. I wonder if these kids have headaches or stomach aches from even younger ages, but lack the expressive language to tell us. In this way they suffer without relief, and their doctors never get the clues they need to make the diagnosis. I would guess that a toddler with a headache is pretty cranky. So I wonder if some emotional or behavior problems in these younger kids--who knows? maybe babies, too--could be resulting from this kind of invisible problem.

But Molly didn't fit an identifiable migraine syndrome. She didn't have any problem with her brain that I could find. 

I asked if she would get headaches when she was outside in the bright sun. Her mom said that she didn't have one when they went to the local county fair the previous weekend. They were outside all day. They went to the petting zoo--but she didn't go in. Her brother, just 2, had no hesitation and had fun with the gentle animals. In fact, the closer she got to the fence around the petting zoo, the more upset she had become. She even was scared to see her brother near the animals. I asked her mother about other things she was afraid of. 

The list was long. She was scared of just about any animal that was live, any bug of any kind but especially spiders, snakes, dark places including closets and under the bed. I asked Molly, and she was open with me. She said that she was afraid of being separated from her family, she was afraid that something bad would happen to her mother, to her father, to her brother, to all of them together, and to herself. She was afraid of strange and new places, new foods. She was afraid of snakes. 

Now, with a little more insight, I asked her about the headache. She said it had hurt. This time I asked her more about what she was feeling during the headache. She said that she was very afraid that it wasn't going to get better. She was afraid that her mother wasn't going to be able to help her and that would make her mother feel bad and it would be her fault.

It's always concerning to me when a 5-year-old complains of a headache. I think Molly had a headache, and I'm not sure what caused it. But though it's not in my textbooks, this is what a panic attack looks like in a preschooler. When I told her mother this, she was able to think of a couple of other unusual meltdowns that seemed to come out of nowhere. They weren't for the usual reasons, when a parent says that the child can't have ice cream for dinner or has to turn off the television. They weren't about defiance, they were about worry. And each time, her mother felt powerless to stop them. In many ways, these events might look behavioral. They include crying, perhaps screaming, maybe pounding fists or feet.

It's the panic attack that made her reaction spiral out of control. Her mother had the right treatment for a headache. Some acetaminophen, closing her eyes in a dark quiet room. But I had to give them something that could make the panic attack less traumatic for the child—and maybe for the mother, too.

I gave the mother a pair of questionnaires I give to parents to help me evaluate anxiety disorders in children. The responses were convincing.

Though Molly had a clear anxiety disorder, she had some big potential advantages as I considered her treatment options. She was smart, she was verbal, and she wasn't afraid of me. The first two points would enable her to cooperate in her treatment in important ways. The last one would, I hoped, enable her to accept my guidance without her anxiety interfering. I discussed treatment options with her mother. She, too, thought that Molly's particular trust in me was worth exploiting to help her. 

Often, with generalized anxiety that includes aspects of the diagnostic subcategories (such as social anxiety disorder, separation anxiety, phobias, and so on) medication is a reasonable approach. But we had these advantages, and her mom and I wanted to try and take advantage of them. We could always revisit a medication option if other approaches didn't work.

I could have sent her to someone really good at Cognitive Behavioral Therapy. In 5-year-olds.
This approach is designed to help patients recognize their dysfunctional thoughts, and manage them in a rational way. Though the technique is well-known in adult psychotherapeutic circles, it's not so well developed for kids. And certainly not with preschoolers. 

In the bigger picture, however, the effects of Cognitive Behavioral Therapy, I think, can be thought of in the same general pool with meditation, yoga, prayer, and clinical hypnosis. They all help people (nothing works for everybody—each helps some people) get relief from thoughts and feelings that are painful or harmful.

What her mother decided was to let me try to teach her self-hypnosis. 








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The Dark Places

Everybody has dark places that they just don't want to go. Sometimes these places are physical locations that we can't avoid.

Evelyn is 9 and has asthma. Controlling her symptoms has been challenging, not because her asthma is so severe, but because her family is very disorganized. As with most chronic conditions, steady routines of preventive care can help to avoid serious episodes. On one Sunday, she was having particular difficulty, so I went to her home to check on her. She turned out basically to be OK and she and her family just needed some hands-on coaching to remind them when and how to use which medication.

A house call is a powerful tool, neither taught nor mentioned in medical training. I have learned a lot from them, and the information from experiencing a child's home is much more substantial than can be inferred from a brief history provided in an office visit. This is particularly true for chronic disease.

Evelyn was eager to show me her room. Her bed was completely hidden under an army of stuffed animals that covered it entirely. There were many clothes on the floor, some clean and some not. There was no door on her closet. She had a desk, which was cluttered with piles of books. Dust was thick everywhere. It looked like nobody in the family was a good housekeeper. I asked her, hinting at the stuffed animals, where her bed was. She pointed to the bed and added, “But I don't sleep there.”

She slept nearly every night on the sofa in the equally dusty living room. I asked, of course, why.

She was afraid of spiders, she explained, as if I were somehow inexplicably dense and couldn't see the obvious.

Evelyn knew there were cobwebs in the corners of her room, and her fear of spiders prevented her from turning off the light when she was in the room. The usual age for the start of specific phobias was about 7, and she said she'd been very afraid of them for a couple of years. She denied any specific traumatic experience, though.

Fear of spiders is one of the most common phobias, and it seems that this affects girls more frequently than boys. But phobias are very common, and we often are embarrassed by them and don't talk about them—we just plan our activities to avoid confronting them. So often when I diagnose an anxiety disorder, I find that the child has specific phobias they never told anyone about. They know that these phobic feelings are not shared by their friends, and sometimes they aren't even comfortable sharing with their parents. Even if the phobias aren't something that restricts their daily life, the child can feel deeply ashamed of what they know is an abnormal perception. So when I am talking to a child who I think might have an anxiety disorder, I always ask about phobias. And when a parent mentions to me that their child has not one but several phobias, I always will consider anxiety.

The key to her asthma control was getting her a low-dust place to sleep, so I offered to come and clean her room with her. She liked this idea and so did her mom. I told them to buy plastic storage bins big enough for clothes and toys, and asked her mother to sew a curtain-rod-to-floor washable curtain to use instead of a closet door. When I returned about a week later, all but one stuffed animal was in a bin. She was welcome to take all of them out whenever she liked, but she could only sleep with one. All the books went in a bin. The clothes went either into a laundry bag in the now-closed closet, or into a bin if clean. Evelyn herself was to take a damp sweeper/mop and dust her bare floor every day. I had a hidden purpose when I proposed this. Sure, it kept the dust level low in her room, which I hoped would help her asthma control. But it gave her control of the corners of her room. By cleaning them herself every day (they shouldn't get too dirty in just a day), she would be reminded that they are really clean, really empty, with no webs or spiders to lurk in the dark.

There was a lot of sneezing while we were cleaning the little room, but we ended up with a lot of dustable smooth surfaces (the floor, the desk, the lids on the bins) that could be kept clean with minimal effort. Within a few weeks, her asthma was much less of a problem. She was still afraid of spiders, but since she herself (with me there helping and protecting her) had cleaned out those dark corners, she could rest much easier in her own bed. I slept better too.