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Headache

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  • See also       

    Acute otitis media 
    Meningitis and encephalitis 
    Head injury

    Key Points

    1. The most common causes of headache are viral illnesses, migraines and tension headaches with tension headaches accounting for 50% of primary headaches in children
    2. Migraine is the most common headache disorder in children presenting to the emergency department
    3. Secondary causes of headache need to be considered in all children presenting with a headache

    Assessment

    Red flag features in red

    History

    Aim to differentiate between primary and secondary headache. Characterise the headaches including pattern of headaches, analgesia use and common triggers

    Consider red flags

    • Acute and severe
    • Progressive chronic headaches
    • Focal neurological symptoms
    • Age under 6yrs
    • Headache/vomiting that wakes child or present on waking (symptoms of raised intracranial pressure (ICP))
    • Consistent location of recurrent headaches
    • Presence of ventriculoperitoneal (VP) shunt
    • Known systemic disorder (hypercoagulable state, genetic disorder, cancer, rheumatological disorder, immunosuppression, hypertension) 

    Consider a psychosocial history in older children and adolescents  

    Examination

    Observations including BP and conscious state 
    Neurological examination – cranial nerve and peripheral nerve examination, consider fundoscopy

    • Stigmata of neurocutaneous syndromes (eg neurofibromatosis and tuberous sclerosis)
    • Increasing head circumference
    • New focal abnormalities
    • Signs of raised ICP (papilloedema, altered mental state, ataxia)
    • Signs of meningism (photophobia, neck stiffness)

    Identify secondary causes of headache 
    Signs of a psychological disorder (see Mental state examination)

    Secondary Headache causes

    Causes Management as per specific condition
    Infectious

    Viral illness
    Sinusitis
    Pharyngitis
    Acute otitis media
    Meningitis
    Encephalitis
    Dental caries

    Headache associated with trauma

    Head injury
    Concussion

    Raised intracranial pressure (ICP)

    Idiopathic intracranial hypertension
    Hydrocephalus
    Other intracranial malformations
    Intracranial neoplasm

    Vascular

    Stroke (haemorrhagic or ischaemic) 
    Intracranial haemorrhage

    Drug related

    Substance use/withdrawal 
    Medication overuse headache

    Psychiatric disorder Anxiety
    Depression
    Somatisation disorders
    Increased psychosocial stressors

    Primary Headache causes

    Headache feature Tension-type headache Migraine with or without aura Cluster headache
    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 i.e. 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

    Migraine triggers

    • Unwell
    • Fatigue
    • Exercise
    • Heat
    • Sun glare
    • Stress
    • Citrus
    • MSG
    • Artificial sweeteners
    • Skipped meals
    • Nuts
    • Onions
    • Salty foods
    • Excess caffeine
    • Chocolate
    • Missed medications

    Management

    Investigations

    Discuss risk factors with a senior clinician and consider intracranial imaging for the following:

    • abnormal neurology, confusion, mental state change
    • signs and symptoms of raised ICP
    • increasing frequency of undiagnosed headache
    • immunosuppressed child
    • new onset severe headache

    Note: neuroimaging is not routinely indicated in children with recurrent headaches and a normal neurological examination.

    Treatment

    Primary Headaches

    General advice

    • Ensure adequate hydration
    • Encourage good sleep hygiene and healthy exercise pattern
    • Avoid triggers such as caffeine, artificial sweeteners and missed meals
    • Address emotional stressors which may be precipitating the headache
    • Simple analgesia for headaches but limit to three times a week to prevent medication overuse headache

    A headache diary can be used to monitor response to lifestyle modifications and treatment.

    Tension-type headache

    Simple analgesia (ie paracetamol +/- ibuprofen) and manage triggers

    Cluster Headache

    • May have a secondary cause – consider neuroimaging
    • Oxygen: 100% oxygen with a flow rate of at least 12 litres per minute via a non-rebreathing mask with a reservoir bag
    • ≥10 yo: sumatriptan intranasally 10–20 mg into one nostril; can be repeated once after at least 2 hours if headache recurs (max 2 doses in 24 hours)
      • limit use to 2–3 times a week to minimise medication overuse headache

    Acute migraine management

    Soon after onset of migraine (usually at home)

    • Ibuprofen 10 mg/kg (max 400 mg)
    • Keep hydrated and rest/sleep in quiet, dark room
    • ≥10 yo: sumatriptan intranasally into one nostril 10–20 mg, can be repeated once after at least 2 hours if headache recurs (max 2 doses in 24 hours)
      • limit use to 2–3 times a week to minimise medication overuse headache
    • Avoid opioids in the treatment of migraine

    On presentation to ED consider

    • Ibuprofen, if not already given
    • Ondansetron 0.15 mg/kg (max 8 mg) oral/IV if vomiting
    • ≥8 yo: chlorpromazine 0.25 mg/kg (max 12.5 mg) IV over at least 30 minutes with 10–20 mL/kg sodium chloride 0.9% (max 1 L); may cause hypotension, monitor BP
    • Rest/sleep in a dark, quiet cubicle

    Consider consultation with local paediatric team when

    Any child presenting with a headache and a red flag symptom/sign

    Consider transfer when

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

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

    Consider discharge when

    • Clinically stable and no red flag features
    • Follow-up arranged as appropriate

    Additional notes

    Migraine

    • It is unlikely that the headache will resolve in the emergency department
    • Discharge home and encourage the patient to continue sleeping in a quiet, dark environment to enable recovery
    • Referral to the patient’s GP may be appropriate for ongoing management of headaches including consideration of preventative treatments

    Parent information sheet

    Headache 
    Migraine

    Last Updated August, 2019

  • Reference List

    1. Australian Medicines Handbook – Children’s Dosing Companion. https://childrens.amh.net.au/auth (viewed 20/6/2019)
    2. Barnes NP. Migraine headache in children. BMJ Clinical Evidence. 2015. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4456852/pdf/2015-0318.pdf
    3. Blume, H. Childhood Headache: A Brief Review. Pediatric Annals. 2017. 46(4), p155-165.
    4. Blume, H. Pediatric Headache: A review. Pediatrics in Review. 2012. 33 (12), 562-576.
    5. British National Formulary for Children. https://about.medicinescomplete.com/publication/british-national-formulary-for-children/ (viewed 20/6/2019)
    6. International Headache Society. IHS Classification ICHD-3. https://ichd-3.org/how-to-use-the-classification/ (viewed 8/11/2018)
    7. Langdon, R et al. Pediatric Headache: An Overview. Current Problems in Pediatric and Adolescent Health Care. 2017. 47(3), p44-65.
    8. Lexicomp. https://online.lexi.com/lco/action/login. (viewed 22/06/2019)
    9. NICE Guidelines. Headaches in over 12s: diagnosis and management. https://www.nice.org.uk/guidance/cg150 (viewed 8/11/2018)
    10. Parisi, P et al. Clinical guidelines in pediatric headache: evaluation of quality using the AGREE II instrument. Journal of Headache and Pain. 2014; 15(1), p57.
    11. Perth Children’s Hospital. Headache guideline. http://kidshealthwa.com/guidelines/headache/ (viewed 8/11/2018)
    12. Sheridan, D et al. Relative Effectiveness of Dopamine Antagonists for Pediatric Migraine in the Emergency Department. Pediatric Emergency Care. 2018. 34(3) p165-168.
    13. Sixsmith, E et al. Managing childhood migraine. Australian Family Physician. 2015. 44(6) p356-359
    14. Starship Children Health. Headaches in Childhood. https://www.starship.org.nz/guidelines/headaches-in-childhood/ (viewed 8/11/2018)
    15. The Royal Children’s Hospital. Headache diary. https://www.rch.org.au/uploadedFiles/Main/Content/clinicalguide/HeadacheDiary.pdf (viewed 8/11/2018)