See also

Acute otitis media
Meningitis and encephalitis
Head injury

Key points

1. Children presenting with headache require careful assessment for red flag features, in order to detect serious underlying secondary causes
2. Most children presenting with headache do not require investigations
3. Supportive therapy with simple analgesia is the mainstay of treatment for most cases of primary headache; opioids are not recommended

Background

• Headaches can be classified as primary (intrinsic to the nervous system) or secondary (due to another underlying condition)
• The most common primary headaches in children are migraine and tension-type headache
• Viral illnesses are the most common cause of secondary headaches in children, while less common but serious causes include CNS infection (meningitis, encephalitis), raised intracranial pressure and haemorrhage
• Headache may also be a manifestation of underlying psychosocial issues

Assessment

History

Consider red flags:

• Age < 4 years
• Headache features (any)
  • Early morning
  • Wakes the child from sleep
  • Triggered or aggravated by coughing, sneezing or positional changes (eg bending forwards)
  • Sudden onset and severe
  • Occipital region
• Associated vomiting without another clear cause
• Significant change in an established headache pattern or progressive worsening
• Focal neurological symptoms
• New onset seizures
• Developmental regression
• Features of meningitis or encephalitis
• Recent history of significant head injury
• Known systemic disorder: haematological condition (bleeding tendency, prothrombotic state), malignancy, rheumatological disorder, immunosuppression, hypertension
• Medications: anticoagulants, antiplatelet agents
• Presence of ventriculoperitoneal (VP) shunt

Other features

• Differentiate between primary and secondary headache (see tables below)
• Family history of migraines/primary headaches
• Consider psychosocial factors which may contribute to headache in older children and  adolescents (see Engaging with and assessing the adolescent patient)
• Characterise the headaches including  pattern of headaches, analgesia use and common triggers

Headache patterns

1. Acute recurrent
   • Migraine
2. Chronic non-progressive
   • Tension-type headache
   • Anxiety, depression
   • Somatisation
3. Chronic progressive
   • Tumour
   • Benign intracranial hypertension
   • Brain abscess
   • Hydrocephalus
4. Acute on chronic non-progressive
   • Tension headache with co-existent migraine

Common migraine triggers include:

• Illness
• Poor sleep
• Exercise
• Menstruation
• Stress
• Heat
• Sun glare
• Foods: citrus, MSG, artificial sweeteners, nuts, onions, salty foods, caffeine, chocolate
• Skipped meals
• Missed medications or medication overuse

Examination

Observations including BP and conscious state

Neurological examination – cranial nerve and peripheral nerve examination, gait, fundoscopy

Stigmata of neurocutaneous syndromes (eg neurofibromatosis, tuberous sclerosis)

Red flag findings include:

• Altered conscious state/confusion
• Increasing head circumference centiles
• Abnormal head position
• New focal neurological abnormalities
• Signs of raised ICP (papilloedema, ataxia, bradycardia with hypertension)
• Signs of meningism (photophobia, neck stiffness)

Primary Headache

Secondary Headache

Management

Investigations

Investigations are not routinely indicated in children with headache presenting without red flag features on history or examination

If red flags present, discuss with a senior clinician and consider intracranial imaging

Treatment of primary headaches

General advice

• Ensure adequate hydration
• Encourage good sleep hygiene and a healthy exercise pattern
• To prevent medication overuse headache, limit use of simple analgesics to less than 15 days per month, and triptans to less than 10 days per month
• Avoid triggers
• Address emotional stressors which may be precipitating the headache
• A  headache diary or App can be used to monitor response to lifestyle modifications and treatment

Tension-type headache

• Provide simple analgesia
  • Paracetamol 15mg/kg (max 1g)
  • Ibuprofen 10mg/kg (max 400mg)
• Manage triggers
• Opioids should not be offered for the acute treatment of tension-type headache

Migraine headache
Soon after onset of migraine (usually at home)

• Paracetamol 15mg/kg (max 1g)
• Ibuprofen 10 mg/kg (max 400 mg)
• Keep hydrated and rest/sleep in quiet, dark room
• Rizatriptan (wafer or disintegrating tablet) may be used if oral analgesics ineffective (sumatriptan nasal spray is no longer available) 
  • >6 yo and <40 kg: 5 mg orally
  • >40 kg: 10mg orally
    
    • can be repeated once after 2 hours if headache recurs (max 2 doses in 24 hours)
  • Propranolol increases the plasma concentration of rizatriptan - avoid or use lower doses of rizatriptan (seek specialist advice) 
• Avoid opioids in the treatment of migraine

On presentation to ED consider

• Paracetamol and ibuprofen, if not already given
• Ondansetron 0.15 mg/kg (max 8 mg) oral/IV if vomiting
• If ≥8 yo:
  • IV Chlorpromazine (Largactil) 0.25 mg/kg (max 12.5 mg) in 10–20 mL/kg sodium chloride 0.9% (max 1 L) administered over 30-60minutes
    OR
    IV Prochlorperazine (Stemetil) 0.15 mg/kg (max 10mg) in 10-20 mL/kg sodium chloride 0.9% (max 1L) administered over 30-60 minutes
  • both agents may cause hypotension and require BP monitoring and administration with IV fluid (as above) +/- additional IV fluids
• Rest/sleep in a dark, quiet cubicle
• Therapeutic nerve blocks may be offered by experienced ED clinicians, or by anaesthetic/pain specialists

Cluster headache

• Simple analgesia has not been shown to be effective
• Administer 100% oxygen with a flow rate of at least 12 L per minute via a non-rebreathing mask with a reservoir bag
• Sumatriptan: intranasally 10-20 mg into one nostril (contralateral side to the headache)
  • can be repeated once after at least 2 hours if headache recurs (max doses 40mg in 24 hours)
• May have a secondary cause, suggest a low threshold for neuroimaging

Consider consultation with local paediatric team when

A child presents with headache and a red flag symptom/sign

Consider transfer when

Neurosurgical intervention required or child requiring escalation in care beyond the comfort of the local healthcare facility

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Child is clinically stable and no red flag features
• Appropriate follow-up has been arranged

Migraine discharge planning and follow up

• It is unlikely that a migraine headache will fully resolve in the emergency department
• On discharge home, encourage the child to continue resting in a quiet, dark environment to enable recovery
• GP follow up or referral to a paediatrician may be appropriate for ongoing management of headaches including consideration of preventative treatments

Parent information

Headache 
Migraine
Head injury

Last updated December 2022