Resources to Support Students with Headache

Headaches affect 1 in 11 children and teens. Thus, every school will need to work with children with headaches and migraine, and every provider seeing children with headaches will need to have interactions with schools. While our goal is to manage migraines and other headaches so that children can attend school and other activities without interruption, there may be times when students need to take medications at school and may need accommodations to manage headache related disability. In addition, education of school personnel about headache and migraine can be very helpful to improve students’ experience at school during and between migraine attacks.  

Migraine Action Plan

The migraine action plan (MAP) is a document that lays out the treatment plan for migraine (or other headache) in a step-wise plan for each child. This can be used at home and at school to ensure treatment is appropriate, clear to everyone caring for the child, and can provide education about migraine for both school staff and families. Scott Turner, DNP and colleagues at AHS have published a model form with 3 sections:

• Green zone: What to do to prevent more headaches: Includes lifestyle recommendations and preventive therapies, strategies and medications with administration instructions and potential side effects.
• Yellow zone: Act fast to treat headaches: Lists actions and acute headache treatments with administration instructions and potential medication side effects.
• Red Zone: Time to get more help: Describes what to do if home/school therapies are not effective.
• Education: This document also provides quite a bit of educational materials about migraine management for schools and families following the formal MAP.  

The article and MAP template are freely available at this link. This MAP form has also been adapted by the Migraine At School initiative so it can be filled in online by providers or families here.

In addition, it is possible to add language to your clinic’s MAP template so it will be accepted as the “medication authorization” form for all schools in your state, although the exact requirements may vary by location*. This has been extremely helpful at our site to reduce the time and effort required each year to prepare the “medication at school” forms for our student patients.

*See the end of this article for example language and additional guidance.

504 Plan - Accommodations for Headache Related Symptoms and Disability

What is a 504 Plan? The purpose of section 504 of the Rehabilitation Act of 1973, is to eliminate discrimination on the basis of disability in any program or activity receiving Federal funding. Students with migraines or headaches may qualify as a student with disabilities if the migraine/headache “substantially limits one or more major life activities.” “Major life activities” include learning and participating in school and is defined as “functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.” The American Migraine Foundation has an information sheet for families about 504 Plans that can be found here. The Headache Relief Guide allows medical providers to generate a basic letter for school, migraine action plan and headache diary.

When to Consider 504 Plan? Providers should consider providing a 504 plan to a student when headaches interfere with function at school. It is reasonable to provide a 504 plan if students are, or are at risk for, being penalized for missing school functions, exams or due dates due to migraine, unable to drink water or use restrooms easily at school, having migraines triggered or exacerbated by modifiable situations at the school, or other situations when migraines or headaches result in limitation of learning or function at school.

What is the Timing of 504 Plans? Once a 504 plan letter has been drafted, the family (or provider, if Release of Information is in place and there are barriers to family sending it directly to the school) will send a copy to the school staff, usually a counselor, administrator, or nurse, ideally with a dated email or other message. The school should reply promptly, and families should expect a meeting with school personnel to discuss the implementation of the 504 plan, or to discuss why the school is denying the request for 504 plan (this fortunately is relatively infrequent in our experience). While there is no federally mandated time course, most schools should respond to the written request within 30 days. For example, the Seattle Public Schools use a timeline that includes 5 school days for acknowledging the request for 504 Plan, 25 school days for determining if an evaluation is needed, 30 school days for the evaluation, and 30 calendar days to develop the 504 plan. 

504 Plan Example: One form we often use for our patients with migraine in the Epic EMR is noted below:

To Whom It May Concern:

@name@ is a patient in my pediatric neurology clinic at XXX. S/he is a @age@ @genderid@ with significant migraine headaches. Our impression is that @his@ pain is real and at times, debilitating. It is very important that @he@ keep up with @his@ schoolwork as much as possible. However, there may be days where @he@ is not able to participate or function at an optimal level due to headache pain and there may be days when @he@ is not able to function at @his@ full ability due to severe headaches. Therefore, we are advocating for accommodations that prevent @fname@ from falling behind in @his@ schoolwork due to migraine.

While each student and school situation is different, accommodations in a 504 plan for chronic headaches may include:

• The ability to work and/or take tests in a quiet and/or untimed environment with limited distractions
• A syllabus or homework packets so that @he@ can complete missed assignments.
• An arrangement at school to store books so she does not have to carry a heavy backpack from class to class
• Providing a process for getting notes/assignments for missed classes
• Shorter or modified homework assignments during times of migraine and or/missed class
• Extra time to make up missed assignments that were late or missed due to illness.
• Time to make up missed exams without penalty
• Excused absences for illness/severe headaches
• Provision of a quiet, dark place to rest in school to try to recover from a spike in headache while staying at school
• Ability to have free access to water (e.g. a water bottle at their desk) and free access to the bathroom when needed
• Ability to leave very noisy or bright environments without penalty, with the provision that work missed can be made up at a later date
• Permission to pursue activities in PE that do not trigger headaches if/when strenuous physical activity exacerbates headaches
• Allow @name@ to demonstrate mastery of academic skills based on quality of work rather than quantity of work Provision of a quiet place to eat lunch with a companion if the general cafeteria environment exacerbates headaches.
• Other:

Overall, it is our goal to help decrease the severity and frequency of headaches while ensuring that the child, school, and family are dealing with the consequences of this medical syndrome as well as possible. I do believe that keeping a student in school and finding ways to treat, and cope with the headaches is typically the best way to manage all of these issues.

Thank you for your consideration.

What to do if 504 is not being followed? Unfortunately, this happens too often. It is reasonable for the family to take a stepwise approach to improve the adherence to the 504:

• Note specific instances of non-compliance, including dates, times, and what was supposed to happen versus what actually occurred.
• Families should communicate with the teacher(s) directly about the 504 plan and the specific accommodations that are not being provided. Consider sending an email outlining the concerns and requesting that the 504 plan be followed, as this can be tracked and has the dates and times of communication automatically documented.
• If the teacher is not responsive, families may escalate the issue to the school principal, counselor or the designated 504 coordinator. The family should request a meeting to discuss the 504 plan and the concerns regarding non-compliance. If the parent/caregiver has concerns that they are not being heard, they may wish to bring an objective and calm family member or friend to the meeting to help understand the process and provide support. If there is still lack of compliance with the 504 plan that is causing harm to the child, families may contact their state’s education ombuds’ office, or consider a formal complaint or legal action. However, if things get to this point, in our experience, it may be also worth considering an alternate school program if that is an option for the student and their family.

Other Online Resources for Managing Headaches and Migraine at School

Migraine at School: This website provides information about migraine and migraine management for parents, students, medical providers, teachers, and school staff. They also provide educational and screening tools to improve migraine care at school. It is an initiative managed by the Danielle Byron Henry Migraine Foundation.   

Migraine Relief Guide: Offers age-appropriate videos for older children and teens about the pathophysiology of migraine, information about lifestyle factors that can affect headaches, and how to take the next steps to improve their symptoms. The “medical provider” section links to more detailed information about migraine management and allows providers to enter information about a patient to provide a report with an individualized migraine management plan, a school treatment plan and headache diary. Try it out!

Miles for Migraine: While this started as a fun run to raise funds for migraine research and care, the website is now host to a variety of amazing resources for people with migraine and their families. In addition to the information about the different fundraising runs and walks throughout the country, the website also hosts educational materials, migraine toolkit information, links to many videos about migraine and migraine management, online and IRL events for kids, families and others with migraine, and support groups for kids, teens and parents dealing with migraine.

Language and additional guidance to consider in your clinic’s MAP template as part of the “medication authorization” form; exact requirements may vary by location:

• Pursuant with RCW 28A.210.260, RCW 28A.210.270, and RCW 28A.210.275, this form is an official request, and includes instructions to administer medications at school. It is signed by legal guardian or parent and a licensed health care provider prescribing within their prescriptive authority. There exists a valid health reason which makes administration of such medication advisable during the hours when the child is in care of the school. This/these medication(s) may be administered by an employee designated by or pursuant to the school board policies. A parent designated adult or trained school employee as defined in RCW 28A.210.260 when complied with the employee, the school district or school, and the members of the governing board, shall not be liable in any criminal action or civil damages as a result of the administration of medication.
• Each medication needs to be properly labeled in the container it originated in and must be labeled with the student's name, date, quantity, and strength per dose unit, Licensed Health Provider name, frequency of administration, and other instructions for administration.
• Medications need to be delivered directly to appropriate school personnel from parent or legal guardian.
• For self-administration, the student may have to demonstrate they have been instructed in the correct and responsible use of the medication to the appropriate school personnel. It is understood that after treatment for anaphylaxis and other conditions as defined by the school, emergency services will be contacted for further treatment.