Swedish school nurses’ view of school health care utilization, causes and management of recurrent headaches among school children

OR IG INAL ART ICLE

Swedish school nurses’ view of school health care utilization,causes and management of recurrent headaches among schoolchildren

Bo Larsson MD (Professor) and Myron Zaluha RN, PNS, RNT

Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala Science Park, Sweden

Scand J Caring Sci; 2003; 17: 232–238

Swedish school nurses’ view of school health care

utilization, causes and management of recurrent

headaches among school children

The present survey was addressed to a representative,

nationwide sample of Swedish school nurses and 174

(69%) responded. They were asked about their views on:

(i) the most usual problems for students that prompt

attendance at school nurses’ offices; (ii) the causes and

management of school children’s headaches and (iii) the

school nurses’ own education with respect to headaches.

Headaches were reported to be one of the most common

problems among adolescents visiting the school nurses’

offices and tension-type headaches were regarded as a

more serious school health problem, compared with

migraine. Various stressors such as family and peer prob-

lems were regarded as important causes of recurrent

headaches. In addition, the school nurses mentioned too

little physical activity, sleep problems and poor eating

habits as related factors, in particular among students with

tension-type headaches. Common management approa-

ches used by the school nurses were to provide informa-

tion about headaches or supportive discussion, recom-

mend follow-up visits, perform vision tests and refer

students to a school physician. About one-fifth to one-

third of the school nurses often gave analgesic medication

to students because of headaches, most commonly used

were paracetamol followed by various NSAIDs. Most

of the school nurses regarded relaxation training as an

‘‘effective or very effective’’ treatment for both migraine

and tension-type headaches, whereas palliative and pro-

phylactic drug treatments were seen as more effective for

migraine. It is suggested that school nurses, who often

provide the first line of treatment for school children and

adolescents with recurrent headaches, also should ad-

minister a cost-effective treatment such as relaxation

training in school settings, where many of the headache

episodes occur. However, school nurses also need to be

properly trained to ensure quality in delivering such

treatment approaches.

Keywords: school, nursing, child, adolescence, therapy,

drug, headache, relaxation.

Submitted 27 February 2002, Accepted 21 January 2003

Introduction

In epidemiological studies, recurrent headaches have been

found to be one of the most common health and pain

complaints reported by school children and adolescents

(1–5). Headaches are also one of the most common health

problems among school children encountered in school

health services, besides minor trauma and infections (6, 7).

Although headache is a common health problem, school

health personal see headaches in school children as

causing only a slight disruption of their school functioning

(8, 9). In a Swedish study, school nurses regarded nonor-

ganic headaches among preadolescents, and in particular

among adolescent girls, to be of higher functional signifi-

cance than school physicians (9).

Bille (10) noted that about one-third of school children

aged 7–13 years with pronounced migraine had sought help

from a physician. In another Swedish epidemiological study

(11), 25% of school children with headaches had sought

help because of their headaches, 10% from the school nurse

and 8% from a physician. Kristjansdottir (5) noted that 5%

of school children with weekly headaches in Iceland had

visited the school physician, a figure identical for those with

infrequent headaches. However, those with frequent

headaches had sought help from the school nurse slightly

more often than those with infrequent headaches. She

concluded that ‘‘in view of the high prevalence (of head-

aches), the low use of school health services should be of

Correspondence to:

Bo Larsson, Professor, Department of Child & Adolescent Psychiatry,

NTNU, N-7489 Trondheim, Norway.

E-mail: [email protected]

232 � 2003 Nordic College of Caring Sciences, Scand J Caring Sci; 2003; 17: 232–238

considerable concern’’. In school-based treatment studies,

about one-third of older adolescents with frequent head-

aches (at least once a week for a year) had visited the school

nurses’ office because of headaches (12). Those who had

consulted a school nurse also had higher levels of headache

activity than nonvisitors. Overall, headaches have been

found to account for 6–10% of all student visits to the school

nurse at all grade levels (6, 7). However, the validity of stated

reasons for visiting the school nurse office because of

somatic complaints including headaches has been ques-

tioned. In a study by Schneider et al. (13), few adolescents

wanted specific medical or psychological help from the

school nurse, but rather wanted to rest. The authors

underlined the importance of examining psychosocial fac-

tors such as stressors in the assessment of somatic complaints

when adolescents visit the school nurse’s office, an issue also

emphasized by others (14). In particular, a smaller group of

adolescents who were high consumers of school health care

because of somatic complaints including headaches were

also found to have more social and emotional problems,

lower academic performance and higher levels of school

absenteeism. Overall, these findings are in line with

outcomes of controlled school-based and clinic studies of

children and adolescents with recurrent headaches (15, 16).

School nurses often provide the first line of treatment for

school children with headaches, and in the majority of

patient-initiated episodes, the care is almost entirely provi-

ded by the school health service (2, 5, 7, 17). The evaluation

of headaches in school children typically includes questions

about headache history and characteristics, medical tests

(temperature and pulse), rest and analgesic medication. In

addition, there may be referral to a (school) physician when

this is seen as appropriate. School nurses also often inquire

about the child’s emotional state and stressors.

In treatment outcome research, school-based relaxation

training administered by school nurses at their offices to

10–15-year-old students in small groups during regular

school hours has been found to effectively reduce their

headache complaints (18). Improvements in headache

activity were also well maintained at a 6-month follow-up.

This is an even more important finding given that relaxa-

tion training provided by teachers in classrooms has not

been successful in effectively reducing students’ headache

complaints (19, 20). The role and contribution of a nurse

clinician in the management of recurrent headaches in

children and adolescents has been outlined by Scham (21),

including the use of relaxation training procedures (22).

Although school nurses meet many school children with

headaches and provide care, their formal education

regarding childhood headaches is often very limited (7).

Their views on the causes and the management of head-

aches are also likely to be primarily based on experiences

from previous practices and not on current research evi-

dence. No previous survey has been conducted in Sweden

regarding school nurse’s views on such practices and

management of recurrent headaches among school chil-

dren and adolescents.

The aims of the present nationwide survey were to

investigate Swedish school nurses’ views on: (i) common

health problems in school-aged children and their rela-

tionships to school level; (ii) the use of school health care

among recurrent headache sufferers seeking help at the

school nurse clinic; (iii) common causes of recurrent

headaches in school-aged children; (iv) the management

and its efficacy for headache problems; and (v) their cur-

rent knowledge and formal education about tension-type

headaches and migraine in school children.

Method

Sample

The present sample of school nurses was selected on the basis

of the national school registry in the Bureau of Statistics

Sweden 1996. The inclusion criteria were public compulsory

and upper secondary (Swedish: gymnasium) schools

(94.8%) with more than 100 pupils. The selected schools

served 90.4% of all pupils in the country. Out of 3510

schools fulfilling these criteria, altogether 252 units (7.2%)

were randomly selected, attended by 8.9% of all students

aged 7–19 years (23). The selection of schools was stratified

by school level [stratum 1: junior (grades 1–3) and inter-

mediate levels (grades 4–6), or combined; stratum 2: schools

with senior levels (grades 7–9) in all combinations of com-

pulsory schools; stratum 3: upper secondary schools (grades

1–3)] and location, i.e. rural, semirural (middle-sized towns)

and urban areas (larger cities including suburbs). The school

nurses in the sample served a mean total of 672 students, and

school sizes ranged from 130 to 1950 students.

Out of 252 eligible school nurses, 174 (69%) responded

to a mailed questionnaire (see below). Except for one

male, all were women, and their ages ranged from 34 to

63 years (mean: 50 years). The majority of the responders

(73%) were experienced school nurses and had worked for

more than 6 years. One-third worked full time.

The attrition rates were found to be related to school

levels according to the following (in ascending order):

20.2, 29.8 and 41.7%; and to location: 29.8, 22.6 and

39.3% for rural, semirural and urban areas, respectively.

The results of chi-square tests showed significant associ-

ations between attrition rate and low/middle grades vs.

gymnasium, v2(1) ¼ 9.02, p < 0.001, and between semi-

rural and urban locations, v2(1) ¼ 5.46, p < 0.05.

Procedures and assessment

A questionnaire designed specifically for the survey was

mailed to school nurses and reminders were sent twice.

Before the survey, the appropriateness and the wording of

the items in the questionnaire were checked at school

� 2003 Nordic College of Caring Sciences, Scand J Caring Sci; 2003; 17: 232–238

Recurrent headaches among school children 233

meetings, where school nurses and doctors were asked to

evaluate the questionnaire and suggest changes when

needed.

The questionnaire

The questionnaire consisted of 38 items covering back-

ground information about the school nurses’ sex, age,

number of years working in school health care, fulltime or

part-time work, type of school levels served and number of

classes in each level. They were also asked to rank 20

common reasons for students visiting the school nurse

clinic on a five-point scale (1 ¼ ‘‘very uncommon’’ to

5 ¼ ‘‘very common’’) (see Table 1). They were then asked

about the average number of students seeking help each

week because of headaches (acute or nonacute), man-

agement procedures (see Table 3), treatments recommen-

ded and used with students in the school clinic (see

Table 4), perceived efficacy and knowledge of these

methods, treatment methods that should preferably be

used within school clinics and by whom (nurse, physician

or others), in addition to 12 listed potential causes behind

recurrent headaches in children and adolescents (see

Table 2). The school nurses were first asked to fill out items

for migraine headaches, then the items for tension-type

headaches (24). They were also asked about the import-

ance of distinguishing between the two types of headaches

and the reasons for doing so (trigger factors, course and

prognosis, treatment methods and other reasons), and to

rate the importance of migraine and tension-type head-

aches as a school health problem. Finally, school nurses

were asked about the scope of education previously

received during nursing and postgraduate training, which

related specifically to headaches in children and adoles-

cents, and whether they perceived a need for education

concerning these issues.

Statistical methods

Differences between groups were analysed by means of the

Mann–Whitney test for ordinal variables; for correlations,

Spearman rank coefficients were used. An alpha level of

p < 0.05 was used to indicate a statistically significant

result, adjusted for multiple comparisons by means of

family-wise Bonferroni corrections.

Results

School nurse visits

The most common reasons for students visiting the school

nurses’ office according to the school nurses are presented

in Table 1. For both younger and older students, ‘‘Wants to

talk or seeks contact’’ was regarded as the most common

cause. For younger students, ‘‘Injuries/Wounds’’ followed

by ‘‘DAMP’’ (attention or hyperactive problems) and

problems with back or neck were common reasons for

attending the school nurses’ offices. Differences between

school levels in regard to these problems were also statis-

tically significant as were differences between levels in

respect of seeking help because of vision problems. For

most of the other reasons, older students visited the school

nurses’ office more often than younger ones. In addition to

‘‘Wants to talk or seeks contact’’, the most common rea-

sons for older students to attend the school nurse office

were knee problems and headaches.

The school nurses reported that a few students in the

lowest grades (1–3) sought help because of acute or non-

acute migraine or tension-type headaches. Overall, few

differences between the number of students seeking such

help because of acute or nonacute migraine were found,

but the rates increased by age. About 3–6% of the school

nurses reported that 6–10 students in the two highest

school levels sought their help each week and 2% of them

reported that 11–20 students sought their help each week,

because of acute migraine. However, for students with

Table 1 Comparisons between school levels in regard to reasons for

students to seek help at the school nurses’ office (figures in percentage

refer to ‘‘Common or very common reasons’’; items are listed in the

same order as in the questionnaire)

Low-middle-level

compulsory school

(grades 1–6)

High-level compulsory

school (grades 7–9)/

secondary school

(grades 1–3)

Injuries/wounds 64% 44%a

Headaches 26% 75%a

Stomach ache 29% 41%

Asthma 21% 33%

Acne/eczema 23% 39%a

Infections 28% 42%a

Home problems 30% 47%a

School relationship

problems

(peers, teachers)

23% 31%

DAMP 45% 20%a

Sad/depressed 7% 26%a

Weight problems 8% 30%a

Nervousness/worry 15% 25%

Wants medication 7% 33%a

Wants to talk or

seeks contact

71% 74%

School problems 8% 34%a

Vision problems 29% 19%a

Back/neck problems 11% 41%a

Sex/gynaecological 3% 23%a

Height problems 11% 27%a

Knee problems 35% 74%a

aSignificant difference between groups (Mann–Whitney test) at the

p < 0.05 level with Bonferroni corrections used.

234 B. Larsson, M. Zaluha


tension-type headaches the proportions seeking help

because of acute headaches were higher than those seek-

ing nonacute help. In addition, the estimates of students

seeking help at the school nurses’ offices because of ten-

sion-type headaches were consistently higher than for

migraine headaches, in particular among students in the

two highest school levels. About 15% of the school nurses

reported that 11–20 students sought their help each week

because of tension-type headaches and 3–4% of them

reported that more than 20 students attended their office

because of these complaints. When number of students

seeking help because of acute headaches were related to

school size (number of students), significant Spearman

rank coefficients were only found for migraine in the

highest levels in compulsory schools (q ¼ 0.29, p < 0.01)

and for tension-type headaches in secondary schools

(q ¼ 0.35, p < 0.01).

Headache elicitors and causes

Of various ‘‘elicitors’’ or causes behind recurrent head-

aches, ‘‘high school demands’’ and hormonal factors were

regarded to be significantly more common among students

with migraine than those with tension-type headaches

(see Table 2). By contrast, stress, problems in the family or

with peers, too little physical activity and somatic disease

were reported to be more common causes of tension-type

headaches than of migraine.

Management of headaches

The school nurses’ management approaches to recurrent

headaches for migraine and tension-type headaches are

presented in Table 3. The school nurses gave information

about headaches and talked to students with tension-type

headaches significantly more often than those with

migraine (z ¼ –5.99, p < 0.001 and z ¼ –2.2, p < 0.05,

respectively). On the other hand, they let students with

migraine rest or sent them home significantly more often

than they did in the case of those with tension-type

headaches (z ¼ –4.80, p < 0.001 and z ¼ –6.92, p < 0.001,

respectively). Overall, information, talking with students

and letting them rest were the most commonly used

management approaches. There was no difference in the

school nurses’ use of analgesics because of headaches in

that 38% used it ‘‘often’’ for migraine and 30% for ten-

sion-type headaches. The drug most often used was para-

cetamol for both migraine and tension-type headaches (48

and 62%, respectively, ranked this drug as the first choice)

and various types of NSAIDs were preferred as the second

option. Acetylsalicylic acid was rarely used.

Providing information about headaches to students,

supportive discussion, letting the student rest, vision tests,

follow-up visits and referrals to school physician were the

most common approaches. Only referrals to school physi-

cian and rest were more frequently used for students with

migraine as compared to those with tension-type head-

aches, whereas other approaches were statistically more

common in the management of tension-type headaches

than migraine. Referrals to other professionals outside

school for evaluation were usually to opticians and oph-

thalmologists, paediatricians and general practitioners.

Few students were referred to a dentist, physiotherapist or

a psychologist. School children with migraine were more

often referred to paediatricians and general practitioners

than those with tension-type headaches, the latter were

more often referred to opticians.

Table 2 School nurses’ view on various causes behind recurrent

headaches among school children (percentages given for the ‘‘import-

ant to very important’’ categories; items are listed in the same order as

in the questionnaire)

Migraine

Tension-type

headaches

Stress 79% 94%a

Family problems 63% 85%a

Peer problems 53% 79%a

Poor eating habits 76% 81%

Sleep problems 81% 85%

High school demands on self 83% 24%a

Somatic disease 20% 66%a

Poor school environment 60% 56%

Too little physical activity 46% 93%a

Psychological problems 34% 44%

Hormonal factors 43% 30%



Table 3 School nurses’ management approaches to recurrent migraine

and tension-type headaches in school children (percentages given for

the ‘‘often’’ category; items are listed in the same order as in the

questionnaire)

Migraine

Tension-type

headaches

Somatic examination 16% 25%a

Referral to school physician 63% 47%a

Blood or urine test 18% 21%

Temperature, pulse, blood pressure 18% 19%

Vision test 63% 84%a

Information about headaches 71% 83%a

Give medication (pain killers) 31% 22%

Supportive discussion 62% 59%

Have the student rest 69% 43%a

Recommend follow-up visits 64% 74%a





As shown in Table 4, school nurses regarded relaxation

training to be effective for both migraine and tension-type

headaches. Analgesic and prophylactic medication were

regarded to be more effective for migraine headaches than

for tension-type headaches. Supportive discussion and

psychotherapy interventions were seen as more effective

in dealing with tension-type headache.

The school nurses were further asked about manage-

ment approaches that they perceived as being appropriate

within school health care, for children and adolescents

with recurrent headaches. They preferred pain-killers,

supportive discussion and relaxation training administered

by themselves for both types of headaches, but saw school

physicians as the most appropriate professional to admin-

ister prophylactic medication.

When school nurses’ views on causes, use and efficacy of

management procedures for recurrent headaches in school

children were related to their experience (number of

years) in school health care, no significant correlation

emerged for any of the two headaches.

Headache type

Almost all of the school nurses rated it as ‘‘important’’ or

‘‘very important’’ to differentiate between migraine and

tension-type headaches in school children. Their reasons

for doing so were that treatment methods (83%), eliciting

factors or causes are different (80%) and that the prognosis

varies (74%). In their evaluation of the importance of the

two types of recurrent headaches as a school health

problem, the school nurses rated tension-type headaches

to be a more important health problem than migraine (Md:

4.4 and 3.7, respectively).

Knowledge and previous education about children’s

headaches

Approximately half of the school nurses reported that they

had ‘‘good’’ or ‘‘very good’’ knowledge about analgesic

medication and relaxation training for tension-type head-

aches, but fewer felt they had good knowledge of migraine

(40 and 35%, respectively). Similar differences were found

for supportive discussion in that 44% of the school nurses

reported good knowledge for tension-type headache and

36% for migraine. Regarding other management approa-

ches, such as prophylactic medication, psychotherapy and

acupuncture, their self-perceived level of knowledge was

consistently lower for both headache types.

During their nursing training and education the majority

of school nurses (62%) had received 0–4 hours of infor-

mation on children’s headaches, 26% had received

between 5 and 15 hours and 11% more than 15 hours.

The corresponding figures for postgraduate education

were: 51, 40 and 9%, respectively. Most of the school

nurses wanted more education on diagnostic and treat-

ment procedures for migraine and tension-type headaches

in children (82 and 88%, respectively).

Discussion

In the present survey, a representative and nationwide

sample of Swedish school nurses were asked about their

views on common reasons for students to attend the school

nurses’ offices, and the causes and management of school

children’s headaches; in addition, they were asked about

their knowledge and desire for more education in these

areas. Although the attrition rate of the study was rea-

sonable (31%), significantly more school nurses from lar-

ger cities and more of those serving adolescents did not

respond to the survey. Because recurrent headaches are an

increasingly important health problem during adolescence,

in particular among girls, this response problem might

influence the validity of the findings. Further, the views of

the school nurses were based on global reports of the

children’s visits and their management of headaches.

These reports are, therefore, likely to be influenced by

recall bias and prospective recordings would provide more

reliable information on these matters. In line with the

findings of the DiMario study (7), all school nurses except

for one, were females and most of them had extensive

experience in school health care. However, their views on

common causes, use and efficacy of various management

approaches of school children’s headaches were not found

to be related to previous experience in school health care.

In line with other international reports, headaches were

regarded as one of the most common reasons for students

seeking help at the school nurses’ office (6, 7, 13, 14, 17).

However, the stated reasons for adolescents seeking help

when presenting with headaches at the school health care

have been questioned in that many of the students only

want to rest and do not seek help specifically for their

headaches complaints (13). Previous reports have sugges-

ted that a minor group of adolescents, who present

with recurrent headaches, also have other psychosocial

problems such as emotional tension, higher school

Table 4 School nurses’ view on the efficacy of various management

approaches of recurrent headaches among school children (percentages

given for the ‘‘effective to very effective’’ categories; items are listed

in the same order as in the questionnaire)

Migraine Tension-type headaches

Give medication (pain killers) 51% 37%

Prophylactic medication 63% 10%a

Supportive discussion 28% 50%a

Psychotherapy 17% 43%a

Acupuncture 33% 24%

Relaxation 53% 79%a





absence, in addition to lower academic performance

(13, 14). These findings are supported by other studies

showing that school children with recurrent headaches

also report more stress than headache-free controls (15).

However, the causal relationships between these areas are

unclear. In the present survey, school nurses typically

regarded various types of stressors such as family and peer

problems, in addition to low physical activity, to be more

common among students with tension-type headaches

than among those with migraine. On the other hand, high

school demands on the students themselves were reported

as being much more common among those with migraine

than tension-type headache sufferers. However, these

views about the role of personality factors among school-

aged headache sufferers are not supported by controlled

clinic or school-based studies (16).

In their management of recurrent headaches, informa-

tion about headaches, supportive discussion, having the

student rest and initiating follow-up visits were the most

common measures undertaken by the school nurses. As

part of their evaluation they also performed vision tests and

often referred students to the school physician. The use of

analgesics because of headaches was endorsed by one-fifth

to one-third of the school nurses. Their prime choice of

drug was paracetamol followed by any of the NSAIDs. Few

school nurses reported the use of acetylsalicylic acid, most

likely because of a fear that students might develop Reye’s

syndrome. In the DiMario (7) study, common diagnostic

procedures performed by school nurses were obtaining

information on children’s headache history, previous head

trauma, neurological and psychological symptoms, in

addition to measuring temperature and pulse.

Although school nurses reported that medication was

not commonly used for students with recurrent headaches,

they regarded palliative and prophylactic medication as

being more effective for migraine than tension-types

headaches. On the other hand, supportive discussion,

psychotherapy and relaxation training were listed as more

effective treatments for school children with tension-type

headaches than those with migraine. Relaxation training

was regarded as ‘‘effective or very effective’’ by 53 and

79% of the school nurses for students with migraine and

tension-type headaches, respectively. About half of the

nurses also reported that this treatment should be provided

to school children within school health care by school

nurses, in addition to palliative analgesic medication and

supportive discussion. Most of the school nurses also

regarded school physicians as the prime professional to

provide prophylactic medication.

This perspective on treatment administration of head-

aches among school children is supported by reports

indicating that the care of the great majority of patient-

initiated episodes of headaches is provided in school

settings (7, 17). Many school children also report that most

headaches occur during school hours or soon closely

afterwards (10). It is very likely that many school-aged

recurrent headache sufferers do not receive optimal

treatments that could be offered to them within regular

school health care. Although it is a common view that

recurrent tension-type headaches, in particular among

school children, are related to various psychosocial prob-

lems, only a few have been shown to be specifically related

to recurrent headaches in case–control studies based on

clinic as well as school samples (25). Further, standardized

relaxation training approaches administered by external

therapists to school children aged 10–19 years within

school settings have been found to effectively reduce their

recurrent headaches, and improvements have also been

well maintained in the long term (16, 18). Similar out-

comes have also been achieved by school nurses admin-

istering relaxation training programmes supervised by an

experienced physiotherapist (18). These findings are even

more important given that attempts to reduce recurrent

headaches among school children by using classroom- and

teacher-based relaxation training have not proved suc-

cessful (19, 20) (see also Fichtel A, Larsson B, unpublished

data).

School nurses are very likely to be the best professionals

to provide ‘‘first-line’’ help to school children with recur-

rent headaches in collaboration with physicians who

should rule out organic diseases as a possible cause.

However, school nurses not only need time to provide

treatment to school children, e.g. in smaller groups during

school time or shortly after school, the results of a recent

effectiveness study on school adolescents suffering from

recurrent headaches underline the importance of school

nurses being properly trained in diagnostic and manage-

ment procedures (18, 21). By using cost-effective approa-

ches such as relaxation training but also teaching children

and adolescents how to optimize their use of analgesics

because of headaches, more headache sufferers can be

offered effective help within school settings, where many

of their headaches occur.

Acknowledgements

We gratefully acknowledge the assistance of statistician Tor

Bengtsson at Statistics Sweden, in the sampling of school

units.

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Documents

Swedish school nurses’ view of school health care utilization, causes and management of recurrent headaches among school children