Headache


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • Background

    The most common paediatric causes are: febrile illnesses, including ENT involvement, migraines and tension headaches.  Meningitis, space-occupying lesions or subarachnoid haemorrhages are far less common but must be considered during any presentation.

    Assessment

    History:

    In evaluation of any child presenting with headache a good history is paramount.  Differentiation between acute and chronic (recurrent) headaches as well as between primary (benign) or secondary headaches is useful.

    Consider “red flag” symptoms/signs 

    • Acute and severe
    • Progressive chronic headaches
    • Focal neurology
    • Age under 3yrs
    • Headache/vomiting on waking
    • Consistent location of recurrent headaches
    • Presence of VP shunt
    • Hypertension 

    Recurrent:

    Tension-type Headaches (~50% incidence):

    • Non-pulsatile band
    • Often end of day
    • Few associated symptoms

    Migraines (~25%):

    • Pulsing pain
    • Nausea
    • Photophobia
    • Phonophonia
    • Often unilateral

    Other:

    • Fever without associated meningism
      • URTI
      • Pneumonia
      • Septicaemia
    • Local sinusitis
      • Focal facial tenderness
      • Otitis media
    • History of recent head injury
    • Meningitis
      • Irritability
      • Decreased consciousness
      • Petechiae/purpura
      • Photophobia/neckstiffness
        • Nb: classic signs less common in paediatric population
    • SAH
      • Sudden onset (“thunderclap”)
      • Vomiting
      • Often occipital
    • Rebound/overuse headache

    Assessment tools: 

    1. Headache Patterns 
    2. HEADSS (Home/Education/Activities/Drugs/Sexuality/Suicide&depression)
    3. International Headache Society: Guidelines 
    Examination:
    • ABC (including blood pressure)
    • General examination (rash – whole body, temperature, toxic appearance, irritability, ENT)
    • Full neurologic examination (including fundoscopy)
    Investigations:

    The following should prompt consideration of intracranial imaging (CT or MRI if available) and discussion with senior medical staff:

    • Abnormal neurology
    • Meningism (consider LP)
    • Marked changes in behaviour
    • Symptoms of raised intracranial pressure
    • Increasing frequency of undiagnosed headaches
    • Onset of severe headache

    NB: May require CT prior to performing LP (discuss with consultant)
    NB2: All children with a serious underlying condition are likely to have one or more objective findings on neurological examination. 

    Management

      headache

    General Advice:

    • Early treatment is important
    • Limit treatment with medication to 3 times per week to prevent overuse/rebound headaches
    • Hydration
    • Avoid caffeine and alcohol
    • Don’t miss meals 

    When to admit/consult local paediatric team

    Any child with a headache with one or more red flag symptom/sign

    When to consider transfer to tertiary centre

    If neurosurgical intervention required

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Parent information sheet:

    Migraine headache (see >> Headaches in children and teenagers)