Children and teens with headaches and migraines have been affected in a variety of ways by these pandemic times. Thinking back, there has been a difference between last spring and this fall and the effect on my patients, particularly in the school environment.

In the early days last Spring, many of my patients who had been having a hard time getting to school every day due to headaches were no longer having chronic daily headaches. For many pediatric patients, the school environment is a huge trigger for migraines and headaches. Physically, the bright fluorescent lights (at times flickering), loud noise, and general commotion are headache triggers. Emotionally and socially, many kids have difficulty tolerating the school environment, whether because of the anxiety and stress around making good grades, challenges with learning issues, or related to bullying and other social stressors. With the sudden closure of school, these triggers were removed. They did have stress around the pandemic experience, but this was much less of an issue for them, as long as they felt safe at home.

The transition during this time to remote learning was variable depending on the school district; some kids were doing ‘zoom’ classes daily, others weekly, and others not at all. There was increased screentime, but it was not usually excessive. They all felt less stress and pressure around school demands, leading to fewer headaches.

One group of patients who had more headaches and more distress were those whose headaches/migraines were managed with scheduled injection procedures (Botox, occipital nerve, and trigger point injections). These services were unavailable for almost 2 months, which did mean many fell behind with their care and had more frequent and severe headaches. Fortunately, most were caught up fairly quickly by mid-July.

This fall, there has been considerable uncertainty about what school would be like, about whether they should do remote learning or be in school. Once the teens knew what they were doing, there was the increased screentime to deal with. School formats were determined over the summer, and while there is still a lot of variability from district to district, there is considerable screentime for everyone.

More than any other factor, the increased exposure to screens has increased both migraine and headache, an additional stressor. I start every visit talking about the effect of screens on their headaches. Invariably, my patients report more headaches, more frequent and severe migraines, and more distress.

Many districts have done an excellent job of balancing scheduling classes and downtime, while others have instituted a more grueling schedule, which I would have trouble with. My clinic put together a handout that I give to everyone about how to manage the screentime, which includes posture, balanced lighting, and blue-light blocking glasses. We also discuss additional school accommodations, used in 504 educational support plans.

There is an emotional piece as well, as they miss their friends and activities. Teens are getting creative in finding ways to be in touch with friends and even see them in a socially distant manner. I have not gotten any push back about wearing masks and staying safe. It is important for them to stay connected with friends during this time. Many teens have a good idea about which of their friends is having a hard time and reach out with support.

Maintaining a consistent schedule is very important for patients with headaches. Getting enough sleep, healthy diet, exercise, and hydration are the keys to reducing headaches. Hydration seems a battle for many, and without the arbitrary school structure, it is more difficult to maintain. Exercise can also be challenging without school sports but so important for stress management for many teens. We often discuss how to keep on track with these lifestyle measures and strategize how to keep on schedule.

Stress management is key to thriving rather than just surviving during these pandemic days. I emphasize the need to take time during the day to breathe, intentionally relax, or release stress physically. This can be doing breath counting for two minutes, running around the house, or doing jumping jacks between classes. This gets their eyes off the screen, relaxes, or energizes the body. I again introduce the idea of using a meditation app or even starting counseling as a way to manage stress. There seems to be more openness around acknowledging stress and seeking help than ever before.

We are all living through this difficult time the best we can. We all have challenges, physically and emotionally, that we are dealing with. We must all be kind and supportive with each other, help when we can, and recognize we are all in the same boat.

Vickie Karian is a nurse practitioner and author of Getting Ahead of Pediatric Headaches: A comprehensive guide for nurse practitioners to manage headaches in children and adolescents.

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