Headache (peds)

See also Headache

Background

Headache Red Flags

Features

• Sudden onset or accelerating pattern
• Maximum intensity of pain at onset (i.e. "thunderclap")
• Worse with valsalva
• Worse in the morning or at night
• No similar headache in past
• Age >50 yr or <5 yr
• Occipitonuchal headache
• Visual disturbances
• Exertional or postcoital
• Family or personal history of SAH, cerebral aneurysm, or AVM
• Focal neurologic signs
• Diastolic BP >120
• Papilledema
• Jaw claudication

Clinical Context

Headache in setting of:

• Infection
• Cancer
• Immunosuppression
• Seizure
• Syncope
• Trauma
• Altered mental status
• Systemic illness (fever, stiff neck, rash)
• Nausea/vomiting
• Patient on anticoagulation, steroids, NSAIDs, antiplatelet

Clinical Features

• Headache

Differential Diagnosis

Pediatric Headache

• Primary headache
  • Migraine
  • Tension
  • Cluster
• Secondary headache
  • Viral illness and fever
  • Post-traumatic
  • VP shunt malfunction
  • CO poisoning
  • Epidural hematoma
  • Subdural hematoma
  • Brain abscess
  • Pseudotumor cerebri
  • Meningitis
  • Space-occupying lesion
  • AVM
  • Sinusitis
  • Dental abscess
  • Otitis media
  • CNS tumor

Evaluation

Exam

• General appearance and behavior
• CNs
• Nuchal rigidity
• Papilledema
• Ataxia
• Other signs of infection (e.g. rhinorrhea, pharyngitis, flank pain, etc.)

Work-up

• Neuroimaging if red-flag features
  • Routine imaging is not indicated in children with recurrent HA headaches and normal neuro exam
  • Consider imaging if abnormal neuro exam, altered mental status, concurrent seizure, severe HA or change in type

Diagnosis

• Predictors of a surgical space-occupying lesion
  • Headache of <6 months duration
  • Sleep-related headache
  • Vomiting
    • Effortless vomiting but no GI complaints suggestive of elevated ICP
  • Confusion
  • Absence of family history of migraine
  • Abnormal findings on neuro exam
  • Torticollis
• Strongly consider imaging in patients under 5 yrs who present with headaches

Management

Headache Type	Treatment	Comment
Migraine	Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR	Ibuprofen superior to acetaminophen in one trial
	Sumatriptan, 10 milligrams via nasal spray (20–39 kg) or 20 milligrams via nasal spray (>40 kg), or 0.06 milligram/kg SC	Nasal or injectable preferred; no difference between oral sumatriptan and placebo
	Rizatriptan, 5 milligrams PO	Efficacy not statistically significant over placebo
	Dihydroergotamine, 0.1 milligram/kg (ages 6–9), 0.15 milligram/kg (ages 9–12), 0.2 milligram/kg (ages 12–16)	Contraindicated in complex migraine
	Prochlorperazine, 0.15 milligram/kg IV	Consider diphenhydramine 1 milligram/kg to prevent or treat dystonic reactions
Cluster	100% oxygen at 7 L/min via non-rebreather mask at onset of headache	Most useful at onset of symptoms, less effective later in course of headache
	Ergotamine, 0.1 milligram/dose (ages 6–9), 0.5 milligram/dose (ages 9–12), 0.75 milligram/dose (ages 12–16)	—
	Sumatriptan	Nasal spray or IM dosing as for migraine
	Lidocaine, 1% solution in ipsilateral nostril	Effective for mild to moderate pain, can instill via atomizer and syringe
	Prednisone, 1–2 milligrams/kg for 10 d with subsequent 7-d taper	Effective at terminating prolonged cluster headaches and preventing recurrence
Tension	Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR	—

Disposition

• Discharge if primary headache provided pain is well controlled and child is well-appearing

See Also

• Headache
• Headache Red Flags
• Migraine
• Cluster Headache
• Tension Headache

External Links

• Pediatric Emergency Playbook Podcast: Pediatric Headache