Together, these symptoms may signify an underlying problem

By Vincent Iannelli, MD 

 Medically reviewed by Huma Sheikh, MD

By themselves, both nosebleeds and headaches are common in children over the age of two and are usually not caused by a serious problem. Together, however, these two symptoms might indicate certain medical issues. Common causes include an upper respiratory infection, sinus condition, or a foreign body in the nose, and serious conditions range from head trauma to tumors. Sometimes, nosebleeds are part of childhood migraines.

Symptoms

Both nosebleeds (epistaxis) and headaches can be caused by a wide variety of issues in children.

Nosebleeds (Epistaxis)

Nosebleeds (epistaxis) are common in mid-childhood, with the incidence highest in children between the ages of three and eight. Roughly 56% of children between the ages of six and 10 will have at least one nosebleed each year.1

Nosebleeds are uncommon before the age of two. A very young child who has a nosebleed should get medical attention.

Nosebleeds occur when small blood vessels in the nose break. Common reasons for nosebleeds include dry air (especially cold air), upper respiratory infections, a foreign body in the nose, picking at the nose, and overuse of nasal decongestants.

Less common, but serious causes may include tumors in the nose and sinus passages or a low platelet count due to conditions including liver disease, kidney disease, bleeding disorders, or blood-related cancers.

Headaches

Headaches in children are also common but rarely affect those under the age of six.2 Headaches may be classified as primary or secondary. Primary headaches aren't caused by an underlying medical illness, and secondary headaches occur due to another condition, such as an infection or head trauma.

Subtypes of primary headaches include tension headaches, migraine headaches, and cluster headaches. Headaches can cause pain in different areas of the head and they may be sharp, dull, throbbing, or constant, and can range in severity.

Parents often wonder when they should worry about childhood headaches.

Headaches are usually of greater concern if:

• The child is younger than six.

• The child has had a previous head injury.

• The headache awakens the child from sleep

• The child has more than one headache per month.

• There are additional symptoms such as fever, neck stiffness, lethargy, lightheadedness, confusion, tremors, vision changes, numbness, muscle weakness, or fainting.

Headaches and Nosebleeds Together

When a child experiences headaches and nosebleeds together, it sometimes narrows down the list of possible causes but also increases the chance that there's an underlying medical condition.

Causes

Looking at some of the potential causes of headaches with nosebleeds in children can be frightening, especially if your child has these symptoms. Keep in mind that common things are common and uncommon conditions are uncommon.

Nevertheless, it is important for parents to have an awareness of some of the more serious causes of headaches and nosebleeds, but keep in mind that allergies are much more common than brain tumors.

Sometimes the headaches and nosebleeds can occur at the same time, or they may occur within a few days of each other.

Allergies (Allergic Rhinitis)

Allergic rhinitis or hayfever is a common cause of both headaches and nosebleeds. With allergies, nosebleeds can be recurrent, and headaches are usually relatively mild.

Children who have allergies may also have other atopic diseases, such as eczema or asthma, and may have a family history of these as well.

Infections

Infections may also cause headaches with nosebleeds, and sometimes fever is present as well. The common cold or sinus infections are most common, especially in children predisposed (such as those who have a deviated septum).

Headaches due to sinus infections may be described as "heavy" and the child may feel pressure behind their eyes and nose.

Although uncommon, headaches with nosebleeds are classic signs of animal-transmitted infections like brucellosis and psittacosis.3

• Brucellosis, which can be transmitted through unpasteurized milk, is often associated with joint aches and fatigue, and it can also cause systemic symptoms.

• Psittacosis is transmitted from birds, including pet birds, and it can cause flu-like symptoms.

Foreign Objects

A foreign body that is lodged in the nasal passages can cause headaches with nosebleeds and it isn't uncommon in young children. For example, a Lego accidentally placed in the nose can lead to nosebleeds and uncomfortable headaches.

When the foreign body has been in place for some time, children often develop a thick, foul-smelling nasal discharge.

Migraine Headaches

Just as with adults, migraines in children may have symptoms other than headaches. Childhood migraine can involve stomachaches, nausea, dizziness, and fatigue along with head pain.

According to a 2015 study in the European Journal of Paediatric Neurology, 1.1% of children with migraines have nosebleeds during an attack, although some scientists believe that the incidence is higher.4

It was found that nosebleeds often preceded the headaches by around three years.

Overall, children who have recurrent nosebleeds are four times more likely to develop migraine headaches.

High Blood Pressure (Hypertension)

Headaches and nosebleeds have been considered a symptom of hypertension, but the link is complex.

According to the American Heart Association, high blood pressure doesn't cause headaches and nosebleeds unless the blood pressure is over 180/120.5 This severe elevation of blood pressure is referred to as malignant hypertension or a hypertensive crisis.

Unlike mild or moderate hypertension, blood pressure this high is not caused by being overweight or poor dietary choices. In children, underlying causes of severe hypertension may include some poisonings (including those related to medications), kidney disease, adrenal tumors, brain tumors, or head trauma.

Trauma

Trauma to the head, face, or nose may lead to headaches and nosebleeds. Children who have either or both of these symptoms after a head injury should be evaluated immediately by a physician.

Tumors

Tumors in the nasal cavity or paranasal sinuses are very uncommon and can lead to both headaches and nosebleeds. These tumors can be benign or malignant and include many types of tumors such as angiofibromas, sarcomas, neuroblastomas, and much more.

Brain tumors, such as olfactory groove meningiomas, may also give rise to these symptoms. While brain tumors are a common concern when a child has headaches, symptoms of brain tumors usually include other neurological signs and not just headaches and nosebleeds alone.

Poisoning

Accidental ingestion of medications (especially blood thinners or anti-inflammatory drugs), household cleaners, and more may result in headaches and nosebleeds.

Vascular Disorders

Conditions marked by abnormalities in blood vessels can give rise to both headaches and nosebleeds. One such example is the genetic disorder hereditary hemorrhagic telangiectasia which can lead to arteriovenous malformations (abnormal connections between arteries and veins in the head and neck).6

Vasculitis, a type of inflammation of the blood vessels that's common in connective tissue diseases such as lupus, may also cause nosebleeds and headaches.

Blood Disorders

Blood disorders ranging from hemophilia to aplastic anemia are very uncommon, but possible causes of these symptoms. They can cause bleeding, which may lead to nosebleeds. If bleeding occurs in the brain, it can cause headaches.

Leukemia

Leukemia, especially acute lymphocytic leukemia, the most common childhood cancer, may lead to headaches.

These cancers may involve the central nervous system, causing headaches. And they can cause nosebleeds due to the effect of cancer on the bone marrow, resulting in a low platelet count.

Coincidence

Just because your child has headaches and nosebleeds at the same time doesn't mean they will always be related. In fact, it could simply be a coincidence that your child has both symptoms, and they can be unrelated.

For example, your child could have a headache from sleeping in an uncomfortable position and a nosebleed from picking their nose.

When to See the Doctor

Call your pediatrician if your child's nosebleed is heavy, won't stop bleeding after 20 minutes, or is causing lightheadedness or fainting. Lethargy, confusion, or the sudden onset of a severe headache may be signs of a serious condition. If your child has a history of head trauma, seek immediate care.

It is important to contact your child's pediatrician about any symptom that concerns you, even if that symptom is only your "gut feeling." Trust your instincts as a parent and call.

Diagnosis

If your child has nosebleeds and headaches, your pediatrician will likely first ask about a history of head injuries. This can sometimes mean urgent care is needed.

The doctor will also ask for more detail about your child's headaches and nosebleeds, including when they began, whether they are worsening or improving, and what additional symptoms you may have noticed.

Some symptoms that can help narrow the possible causes are:

• Fatigue

• Fever

• Bruising and/or pallor

• Pain

• Lightheadedness or dizziness

• Weight loss

• Nausea and/or vomiting

• Neurological symptoms

• Confusion

Your pediatrician will then perform a physical exam. Depending on the findings, they may recommend further evaluation. For example, they may refer your child to an ear, nose, and throat (ENT) specialist if there's a concern about serious sinus problems.

Lab Tests

A number of different lab tests may be recommended:

• Complete blood count (CBC): A CBC can determine if your child has anemia (low red blood cells) or thrombocytopenia (low platelets).

• Chemistry panel: The comprehensive blood and urine evaluation will include kidney and liver function tests

• Coagulation tests: Bleeding tests can determine if your child's blood is clotting normally.

Other Tests

Imaging tests may include computed tomography (CT) or magnetic resonance imaging (MRI) to evaluate the nasal cavities and sinuses or the head.

If your child's CBC is abnormal and your pediatrician is suspicious about leukemia, aplastic anemia, or other serious conditions, a bone marrow biopsy may be ordered. Bone marrow studies are typically performed if signs of anemia, thrombocytopenia, fever, lymphadenopathy (swollen lymph nodes), and hepatosplenomegaly (swollen liver and spleen) cannot be explained.7

Sources

Schechter M, Stevens DM. Chapter 146: Epistaxis. American Academy of Pediatrics Textbook of Pediatric Care (Second Edition). Itasca, FL: American Academy of Pediatrics.

Kang BS, Lee J, Choi JH, Kwon HH, Kang JW. Clinical manifestations of headache in children younger than 7 years. Korean J Pediatr. 2018;61(11):355-61. doi:10.3345/kjp.2018.06331

Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (9th Edition). Amsterdam: Elsevier.

Ahmed M, Lam J. Migraine and nosebleed in children case series and literature review. Eur J Paed Neurol. 2015;19(1):98-101. doi:10.1016/j.ejpn.2014.09.001

American Heart Association. What are the symptoms of high blood pressure?

Uğurlu N, Emre S, Yülek F, Akcay EK, Sengun A. Hereditary hemorrhagic telangiectasia with multiple fusiform retinal aneurysms. J Ocul Biol Dis Infor. 2012;5(2):48-50. doi:10.1007/s12177-013-9100-y

Calvet L, Pereira B, Sapin AF, Mareynat G, Lautrette A, Souweine B. Contribution to diagnosis and treatment of bone marrow aspirate results in critically ill patients undergoing bone marrow aspiration: a retrospective study of 193 consecutive patients. J Intensive Care. 2017;5:67. doi:10.1186/s40560-017-0263-7

By Vincent Iannelli, MD
 Vincent Iannelli, MD, is a board-certified pediatrician and fellow of the American Academy of Pediatrics. Dr. Iannelli has cared for children for more than 20 years.