When Children’s Headaches Speak for Their Feelings

This new emerging research with novel insights, published by Hye Eun Kwon in 2025, looks at pediatric headache and dizziness through a fresh lens: not just as primary headache disorders, but also as possible somatic expressions of psychological distress in children and adolescents.

Somatization refers to the process by which emotional strain and stress show up as physical symptoms—think of a worried child whose “stomach hurts” every school morning, or a teenager whose headaches ramp up during exam season. In this review, headache and dizziness sit at the crossroads between neurology and psychology, and the article argues that we need an integrated way of understanding and treating them in youth.

Within this context, non-pharmacological interventions such as cognitive behavioral therapy (CBT) and biofeedback are highlighted as central tools. Very briefly, biofeedback uses real-time information from the body, such as muscle tension, heart rate, or skin conductance, to help a person learn to consciously regulate their physiological state. Neurofeedback is a closely related approach that uses EEG to train brain activity patterns directly. Both approaches hinge on the idea that the brain and body can learn new, healthier patterns through practice.

The review emphasizes that pediatric chronic primary headache (CPH) and somatic symptom and related disorders (SSRD) share a common mechanism: central sensitization in a still-developing nervous system. It also underscores that medications, especially prophylactic drugs for headache, often underperform in pediatric trials, while CBT and biofeedback repeatedly emerge as key components of effective care. This sets the scene for a more holistic, skill-based, and developmentally sensitive way of working with children who suffer from disabling headaches.

Methods

This paper is a narrative review that follows a clear conceptual pathway: (1) clarifying the phenomenon of somatization in youth, (2) describing the shared neurobiological underpinnings of chronic headache and somatic symptom presentations, (3) outlining risk factors and diagnostic differentiation, and (4) contrasting pharmacological with non-pharmacological management strategies.

A central organising concept is the idea of central sensitization in the developing brain. Rather than treating pediatric headache or somatic symptom presentations as purely psychological or purely neurological, the review synthesizes imaging, longitudinal, and clinical evidence to argue that repeated stress and pain experiences reshape brain circuits involved in pain perception, emotion regulation, and interoception. This is framed as a transdiagnostic mechanism that helps explain why chronic primary headaches, functional somatic syndromes, and psychiatric conditions so often cluster together in young people.

On the clinical side, the article walks through established diagnostic frameworks. Chronic primary headaches (such as chronic migraine, chronic tension-type headache, and new daily persistent headache) are defined according to the International Classification of Headache Disorders, 3rd edition (ICHD-3). Somatic symptom and related disorders, in contrast, are defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), with a focus on maladaptive cognitive, emotional, and behavioral responses to physical symptoms.

From a treatment perspective, the review contrasts typical pharmacological strategies (anticonvulsants, beta-blockers, antidepressants) with psychosocial and behavioral interventions, especially CBT and biofeedback. Pharmacological agents are generally used for headache prophylaxis in primary headache disorders or to treat comorbid anxiety and depression in SSRD. However, the article highlights that major pediatric trials have failed to show robust superiority of medications over placebo for migraine prevention.

In parallel, the review points to CBT and biofeedback as core non-pharmacological tools. CBT is used to reframe catastrophic thinking, reduce health-related anxiety, and build coping skills. Biofeedback interventions in the pediatric headache literature often focus on teaching children to regulate muscle tension, autonomic arousal, or other physiological markers associated with pain and stress. While this article does not delve into specific EEG-based neurofeedback protocols, its framework naturally extends to self-regulation approaches that target brain activity directly, particularly when these are embedded in a broader interdisciplinary care model.

Results

The review’s key findings can be grouped into three broad domains: shared mechanisms, differential diagnosis, and treatment implications.

First, on the mechanistic side, the paper emphasizes central sensitization as a common thread running between chronic primary headache and somatic symptom presentations in youth. Children and adolescents, with their highly plastic and still-maturing brains, appear especially vulnerable to maladaptive sensitization. Neuroimaging studies suggest altered connectivity within pain-related networks and disruption of resting-state activity. Early life stress, maltreatment, and chronic psychosocial strain further prime the stress system and immune system, increasing the likelihood that pain and somatic symptoms will become chronic rather than resolving.

Second, diagnostically, the article stresses that chronic primary headache and headache as a somatic symptom can appear almost indistinguishable in the clinic. The crucial difference lies not so much in the headache itself as in the surrounding psychological and functional landscape. In CPH, the diagnosis rests on specific headache features: frequency, duration, associated symptoms such as photophobia or phonophobia, and clear alignment with established ICHD-3 categories. In SSRD, by contrast, the hallmarks are excessive worry, health anxiety, disproportionate functional impairment, and maladaptive behaviors such as repeated reassurance seeking or avoidance. Alexithymia—difficulty recognizing and expressing emotions—often complicates the picture, making emotional drivers less visible while amplifying physical complaints.

Third, in terms of treatment, the paper highlights a striking divergence in how medication is used and how effective it tends to be. For primary headaches, prophylactic medications like topiramate, amitriptyline, or beta-blockers are often prescribed, but pediatric trials have shown limited efficacy, with some large studies finding no clear advantage over placebo. For somatic symptom presentations, medications are usually adjunctive and aimed at comorbid anxiety or depression, rather than at the somatic symptom itself.

Across both groups, however, the article converges on shared non-pharmacological strategies. Psychoeducation, CBT, and biofeedback are presented as essential components of care that can improve function, reduce symptom burden, and limit unnecessary medical investigations. Biofeedback, in particular, is described as a way to promote self-regulation and reduce symptom frequency and intensity by helping children “see” their physiology and learn to influence it over time. The review concludes that effective management depends on integrated, interdisciplinary care, early recognition of somatic presentations, and a strong emphasis on functional improvement rather than symptom eradication alone.

Discussion

This review invites a shift from a narrow, symptom-focused approach to pediatric headache toward a more integrated, developmentally informed model. By foregrounding central sensitization and somatization, it helps explain why some children with headaches do poorly despite multiple medications, imaging studies, and specialist visits: the problem is not just in the head, but in the interaction between brain, body, stress, and meaning.

Clinically, the article underscores the importance of a careful history that looks beyond headache frequency and location. Clues such as multiple medically unexplained symptoms, pronounced health anxiety, frequent school absenteeism, and either dramatic distress or striking emotional flatness (alexithymia) should raise suspicion that a somatic symptom and related disorder may be in play. At the same time, it warns against either-or thinking: many children meet criteria for both chronic primary headache and SSRD, and their headaches can become a kind of amplifier for broader emotional strain.

For families, this integrated framework can be profoundly relieving. When a clinician explains that the child’s headaches are real, not fabricated, but that they are also shaped by stress, emotion, and a sensitized nervous system, it opens a doorway to hope and agency. Instead of a long, frustrating search for “the” pill or “the” lesion on MRI, the focus shifts toward skills: understanding the body’s alarm system, reducing avoidance, gradually resuming activities, and practicing self-regulation through CBT and biofeedback.

For other health professionals, the review is a reminder that over-reliance on medications in pediatric headache is not evidence-based. If large prevention trials show that common prophylactic drugs are no better than placebo, then continuing to escalate doses or switch from one agent to another—without addressing psychological factors and central sensitization—may inadvertently reinforce helplessness and medical dependency. The article points instead toward a collaborative, interdisciplinary model in which pediatricians, neurologists, psychiatrists, psychologists, and allied health professionals share a common biopsychosocial language and treatment plan.

For clinicians working with biofeedback and neurofeedback, the implications are rich. The paper highlights biofeedback as a key non-pharmacological option with evidence for reducing headache burden in children. In practice, this may involve training down excessive muscle tension, stabilising autonomic arousal through heart rate variability-based protocols, or working with electrodermal activity to decrease stress reactivity. Neurofeedback can be conceptualised as an extension of this logic to the brain itself: for a child with chronic headaches and co-occurring anxiety, for example, one might explore protocols aimed at reducing high beta activity associated with hyperarousal at frontal or central sites, or enhancing sensorimotor rhythm to support inhibitory control and physiological stability.

Interpretively, the article sits within a broader wave of research showing that early, psychologically informed interventions can change the trajectory of somatic symptom and functional pain disorders in youth. Randomized trials of CBT for pediatric headache have demonstrated reductions in headache frequency and disability, while meta-analytic work on somatic symptom and functional syndromes suggests that structured psychological treatments can meaningfully reduce symptom severity and healthcare use. The inclusion of biofeedback alongside CBT in this review reflects an emerging consensus: teaching children to notice and regulate their internal states is not an optional add-on, but a central ingredient of effective care.

At the same time, the review is appropriately cautious. It calls for better pediatric-specific diagnostic tools, longitudinal studies to map prognosis, and rigorous evaluation of integrated care programs. For neurofeedback and biofeedback practitioners, this means embracing both the optimism of a strong conceptual framework and the humility of ongoing research. The goal is not to claim a miracle cure, but to fit these self-regulation methods into a coherent, evidence-aligned, and compassionate model of care for young people whose bodies are speaking their distress through pain.

Brendan’s perspective

If you work with kids who have chronic headaches, this review feels a bit like someone finally turning on the lights in a room we’ve been stumbling through for years.

One of the most striking messages is that medications, especially for migraine prevention in children, often do far less than we once hoped. When a large randomized trial shows that two widely used prophylactic drugs fail to beat placebo in reducing headache frequency, it becomes hard to maintain the illusion that “we just need to find the right pill.” That is sobering—and also strangely liberating—because it pushes us toward methods that build skills instead of dependency.

Now bring in biofeedback and, by extension, neurofeedback. The paper highlights biofeedback as a core, evidence-supported option for pediatric headache and somatic symptom presentations. We also have meta-analytic work (outside this review) suggesting that structured psychological and behavioral interventions can match or even outperform medication in many pediatric pain and somatic conditions, often with longer-lasting benefits and fewer side effects. When you put those pieces together, the story that emerges is not “biofeedback versus medicine,” but “self-regulation approaches stepping into a space where medicine alone is underperforming.”

From a practical neurofeedback standpoint, I read this review as a call to lean into that self-regulation story. Imagine framing treatment for a 13-year-old with chronic headaches like this: “Your brain and body have become extra good at sounding the alarm. Our job is to teach that alarm system how to calm down again. We are not fighting your body; we are teaching it new tricks.” That message is fundamentally different from “We’ll try another pill and see what happens,” and children hear the difference.

In protocol terms, this often means widening the lens beyond a simple “migraine protocol.” For a child whose headaches are intertwined with anxiety and school avoidance, I tend to think in layers:

• First, stabilisation: consider training sensorimotor rhythm (around 12–15 Hz) at sites such as C3, Cz, or C4 to enhance inhibitory control and reduce general cortical irritability. The goal is a nervous system that is less jumpy and more anchored.

• Second, arousal regulation: for those with clear hyperarousal and worry, down-training high beta activity (for example, 22–30 Hz) at frontal or central sites, combined with heart rate variability biofeedback, can help bring the whole system out of “red alert” and into a more flexible, responsive state.

• Third, quieting the noise: in some highly sensitized kids, it's possible to do posterior alpha training, like we do in adults. There are some adaptations needed to the standard paradigm to make it kid-friendly, and there is notably less research out there on posterior alpha training in kids, so it's not my number 1 stragegy. Still, I've found it can work, and that it's especially beneficial when headaches are accompanied by emotional lability or functional neurological symptoms.

Critically, I would almost never run these protocols in isolation. The review’s emphasis on CBT, psychoeducation, and family context matches what many of us see clinically: sessions are more effective when children understand why they are training, when parents stop inadvertently reinforcing the sick role, and when gradual re-engagement with school and activities is built into the plan. Neurofeedback and biofeedback become tools inside a broader behavioural and relational container, not free-floating gadgets.

What I find particularly encouraging is the way this framework reframes “natural” and “self-driven” approaches without slipping into pseudoscience. We are not saying, “Throw away all your meds and just do brain training.” Instead, we are saying: “Here is evidence that your child can learn to modulate their own physiology, that practice physically reshapes brain networks, and that these skills may serve them long after the headaches have settled.” For a 10-year-old learning to lower their muscle tension or shift their EEG patterns, the real win is not just fewer headaches next month. It is the discovery that “I can influence what happens inside me.” That belief is rocket fuel for perseverance and resilience later in life.

This is where the comparison with medication becomes ethically interesting. A pill can be helpful, especially in acute phases or when comorbid conditions are severe. But a pill does not teach a child how to navigate stress, name feelings, or dial down a sensitized nervous system in real time. Biofeedback and neurofeedback, by design, hinge on repetition, feedback, and mastery. They turn physiology into a game the child can win, session by session. And along the way, they carry implicit lessons about patience, frustration tolerance, and sustained effort.

Of course, we need better trials that put these approaches head-to-head with optimized medication regimens and combined treatments, especially in pediatric samples. We also need studies that reflect real-world clinical practice rather than highly restricted research protocols. But even with those caveats, the trajectory is clear: when medications stumble and self-regulation methods repeatedly show good outcomes with minimal side effects, it is no longer speculative to place biofeedback and neurofeedback near the centre of pediatric headache and somatic symptom care.

In short, this review backs up what many clinicians already feel in their gut: children with chronic headaches do not just need symptom suppression; they need tools. Biofeedback and neurofeedback are not just “natural” alternatives, but structured, evidence-aligned ways of teaching the developing brain how to feel safe in its own body again. And that lesson, once learned, tends to stick.

Conclusion

This review of pediatric headache as a somatic symptom brings together neurology, psychiatry, and behavioral medicine in a genuinely integrated way. By framing chronic headaches and somatic symptom presentations as different faces of a sensitized, developing nervous system, it explains why purely pharmacological strategies often disappoint and why skill-based approaches such as CBT and biofeedback consistently emerge as central to effective care.

For clinicians, it underscores the importance of looking beyond the pain itself to the broader context: risk factors, psychological responses, family dynamics, and patterns of functional impairment. For families, it offers a compassionate explanation that validates the child’s suffering while opening doors to active, empowering treatments. For biofeedback and neurofeedback practitioners, it provides a robust conceptual and clinical justification for positioning self-regulation training as a core component of pediatric headache management.

Ultimately, the message is hopeful: when we stop chasing a single cause or a single medication and instead help children understand and retrain their own brain–body systems, we are not just treating headaches. We are nurturing resilient nervous systems and giving young people tools they can carry into the rest of their lives.

References

Kwon, H. E. (2025). Headache as a somatic symptom in pediatrics: Diagnosis and integrated management. Headache and Pain Research, 26(3), 193–199. https://doi.org/10.62087/hpr.2025.0016