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Headache

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  • 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

    Headache patterns

    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

    Headache feature

    Tension-type headache

    Migraine with or without aura

    Cluster headache

    Age

    All ages

    All ages

    Typically ≥12 years of age

    Pain location

    Bilateral

    Unilateral or bilateral

    Unilateral, often around the eye

    Pain quality

    Pressing/tightening (non-pulsatile)

    Pulsatile

    Variable (sharp, burning, throbbing or tightening)

    Pain intensity

    Mild to moderate

    Moderate to severe

    Severe to very severe

    Headache pattern

    Chronic non-progressive

    Acute recurrent

    Acute recurrent

    Effect on activities

    Not exacerbated by activity

    Aggravated by normal activities

    Can cause restlessness and agitation

    Associated symptoms

    None
    May be precipitated by significant stress ie emotional distress, poor sleep, missed meals

    Nausea and vomiting, photophobia, phonophobia
    With aura: presence of focal neurological symptoms, usually visual, sensory or speech changes before onset of headache (aura lasts less than one hour)

    Autonomic symptoms ie ipsilateral conjunctival injection, tearing, rhinorrhoea, eyelid swelling, facial sweating, meiosis or ptosis  

    Duration

    Hours to days

    May only last 30 minutes in young children, up to 72 hours in adolescents

    Minutes to a few hours


    Secondary Headache

    Causes

    Specific conditions to consider

    Infectious

    Viral illness
    Sinusitis
    Pharyngitis
    Acute otitis media
    Meningitis
    Encephalitis
    Intracranial abscess
    Dental caries

    Headache associated with trauma

    Head injury

    Raised intracranial pressure (ICP)

    Idiopathic intracranial hypertension
    Hydrocephalus
    Intracranial neoplasm
    Other intracranial malformations

    Vascular

    Stroke
    Intracranial haemorrhage

    Drug related

    Substance use/withdrawal 
    Medication overuse

    Psychiatric disorder

    Anxiety
    Depression
    Somatisation disorders
    Increased psychosocial stressors
    See Mental state examination

    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
    • 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
    • Sumatriptan may be used if oral analgesics ineffective
      • ≥12 yo: 10-20mg intranasally into one nostril
        • can be repeated once after 2 hours if headache recurs (max 40mg in 24 hours)
      • 6-12 yo: 10mg intranasally into one nostril
        • Can be safely used in this age group, although efficacy is less well-established
    • 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 November 2022

  • Reference List

    1. Australian Medicines Handbook – Children’s Dosing Companion. https://childrens.amh.net.au/auth (viewed 10 July 2022)
    2. Barnes, N. Migraine headache in children. BMJ Best Practice. 2020. Retrieved from https://bestpractice.bmj.com/topics/en-gb/678 (viewed 10 July 2022)
    3. British National Formulary for Children. https://about.medicinescomplete.com/publication/british-national-formulary-for-children/ (viewed 10 July 2022)
    4. Brousseau, DC et al. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004. 43(2):256-262. doi:10.1016/s0196-0644(03)00716-9 
    5. Blume, HK. Childhood headache: a brief review. Pediatr Ann 2017. 46:e155 – e165.
    6. Patniyot, IR et al. Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review. Headache. 2016. 56(1):49-70
    7. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition https://journals.sagepub.com/doi/full/10.1177/0333102417738202 (viewed 10 July 2022)
    8. Kelly, M et al. Pediatric headache: overview. Curr Opin Pediatr. 2018. 30(6):748-754. doi:10.1097/MOP.0000000000000688.
    9. Lewis, DWet al. Practice parameter: evaluation of children and adolescents with recurrent headaches. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002. 59:490 – 498.
    10. NICE Guidelines. Headaches in over 12s: diagnosis and management. https://www.nice.org.uk/guidance/cg150 (viewed 10 July 2022)
    11. NICE Guidelines. Suspected neurological conditions: recognition and referral. https://www.nice.org.uk/guidance/ng127  (viewed 10/07/2022)
    12. Migraine & Headache Australia. https://headacheaustralia.org.au/ (viewed 10July 2022)
    13. Sheridan, DC et al. Pediatric Migraine: Abortive Management in the Emergency Department. Headache: The Journal of Head and Face Pain,. 2014. 54: 235-245. https://doi.org/10.1111/head.12253
    14. Sheridan, D et al. Relative Effectiveness of Dopamine Antagonists for Pediatric Migraine in the Emergency Department. Pediatric Emergency Care. 2018. 34(3) p165-168
    15. Sixsmith, E et al. Managing childhood migraine. Australian Family Physician. 2015. 44(6) p356-359
    16. UpToDate, Headache in Children: Approach to evaluation and general management strategies, https://www.uptodate.com/contents/headache-in-children-approach-to-evaluation-and-general-management-strategies (viewed 29 July 2022)
    17. UpToDate, Acute Treatment of Migraine in Children, https://www.uptodate.com/contents/acute-treatment-of-migraine-in-children?search=paediatric%20headache&topicRef=2842&source=see_link (viewed 30 July 2022)
    18. Werner, K et al.Intravenous Migraine Treatment in Children and Adolescents. Curr Pain Headache Rep. 2020. 24(8):45. doi: 10.1007/s11916-020-00867-7