Headache in children

Headaches in children are classified as primary (e.g., migraine, tension-type headache) or secondary (e.g., caused by infections, neoplasms, or structural causes). Following a detailed clinical evaluation, primary headaches are typically diagnosed clinically if there are no red flags for pediatric headache, neurological examination is normal, diagnostic criteria are met, and no other cause is suspected. Children with red flags (e.g., abnormal findings on neurological examination or change in headache characteristics) should be evaluated for a secondary cause of headache, which may involve imaging (e.g., MRI brain) and/or laboratory studies (e.g., lumbar puncture). If urgent or life-threatening causes of pediatric headaches are suspected, patients should be stabilized immediately and given time-sensitive treatments. For nonurgent causes, management includes acute symptomatic management, nonpharmacological preventive interventions, and condition-specific treatments.

Primary headaches ^[1]

• Migraine in children
• Tension-type headache in children
• Trigeminal autonomic cephalalgias (e.g., cluster headaches, paroxysmal hemicrania, hemicrania continua)
• Other primary headaches (e.g., cough headaches, headaches due to physical exertion, primary stabbing headache)

Secondary headaches ^[1][2]

See "Causes of headaches" for additional etiologies.

• Infectious
  • Intracranial infections (e.g., meningitis, encephalitis, abscess, empyema)
  • Systemic infections (e.g., influenza)
  • Head and neck infections (e.g., sinusitis, otitis media, dental infection)
• Neoplasm
  • Pediatric primary brain tumors
  • Neoplastic meningitis (e.g., meningeal leukemia)
• Cerebrovascular
  • Subarchnoid hemorrhage
  • Subdural hemorrhage
  • Vascular malformations (e.g., arteriovenous malformation, fistula, aneurysm)
  • Cerebral venous thrombosis
  • Hypertensive crises
• Structural
  • Hydrocephalus
  • Chiari malformations
• CNS pressure changes
  • Intracranial hypertension (e.g., pseudotumor cerebri syndrome)
  • CSF leak or post-lumbar puncture headache
• Posttraumatic headache
  • Traumatic brain injury (TBI) and mild traumatic brain injury (mTBI)
  • Postconcussion syndrome
• Drug-related or toxin-related
  • Medication overuse headache (rebound headache) from acute pain medications
  • Adverse effects of prescription medications (e.g., hormonal contraceptives, psychostimulants)
  • Caffeine withdrawal headache
  • Carbon monoxide poisoning
• Musculoskeletal
  • Cervicogenic headache
  • Temporomandibular joint disorder
• Other
  • Uncorrected refractive errors
  • Obstructive sleep apnea
  • Psychiatric conditions (e.g., somatic symptom disorder)

Approach

For clinically unstable patients and/or those with suspected urgent or life-threatening causes, immediate management interventions are indicated. ^[3]

• Perform an ABCDE survey.
• Consider advanced airway management in children for the following:
  • Inability to protect the airway (e.g., significantly depressed consciousness)
  • Signs of impending herniation
• Establish IV access and administer supportive care as needed, e.g.:
  • Immediate hemodynamic support
  • Analgesia (see "Pain management in children")
  • Antiemetics (see "Antiemetics in children")
• Initiate additional measures as indicated.
  • Signs of increased ICP: ICP management
  • Suspected ischemic stroke and/or intracranial hemorrhage: neuroprotective measures
  • Seizures: management of acute seizures
• Identify and treat the underlying condition, e.g.:
  • Consider urgent neuroimaging and/or targeted laboratory studies (see "Diagnostics for headache in children").
  • Initiate condition-specific management (see "Urgent and life-threatening causes of pediatric headache").
• Maintain NPO status until need for neuroimaging with sedation and/or surgery is excluded.
• Immediately consult appropriate specialists (e.g., neurology, neurosurgery) if any of the following are suspected:
  • Acute stroke or cerebral venous sinus thrombosis
  • Impending brain herniation
  • Acute hydrocephalus
  • VP shunt malfunction and/or infection
  • Mass effect, epidural hematoma, or subdural hematoma with rapid deterioration

Headache red flags in children ^[2][4][5]

Red flag features suggest a secondary headache disorder and should prompt further evaluation.

• Signs of systemic illness, e.g.:
  • Weight loss, fever
  • Abnormal pediatric growth patterns or pubertal development
• Neurological abnormalities, e.g.:
  • Focal neurological deficits
  • Manifestations of increased intracranial pressure (e.g., papilledema) ^[5]
  • Signs of meningeal irritation
• Abnormal headache characteristics, e.g.:
  • Acute and/or sudden onset
  • Worsening headache or change in headache characteristics
  • Triggered by positional changes and/or Valsalva maneuver
  • Nocturnal or early morning headache
• Other features
  • Age < 6 years
  • Seizures
  • Vomiting
  • No family history of a primary headache disorder

Isolated occipital headache was previously considered a red flag, but it has low specificity for serious pathology (e.g., posterior fossa brain tumors, vertebral dissection, Chiari malformation) and should be interpreted in the context of other red flags. ^[1][6][7]

Focused history ^[2][5][8]

• Pain characteristics
  • Timing: age at onset, sudden or gradual onset, duration, frequency
  • Location: unilateral, bilateral, diffuse, radiating pain
  • Quality: throbbing or pulsatile, tight or squeezing, stabbing
  • Severity: pain scale assessment, impact on patient's daily activities (e.g., school, play, sleep)
  • Progression: change in frequency, severity, duration, pattern, or functional impact
• Associated symptoms
  • Classic migraine features: prodromes, aura, nausea, photophobia, phonophobia, osmophobia
  • Cranial autonomic symptoms: ptosis, miosis, lacrimation, rhinorrhea, conjunctival injection ^[5]
  • Neck pain or tightness
• Exacerbating and alleviating factors
  • Physical exertion, Valsalva maneuver, and/or positional changes
  • Hormonal changes
  • Preceding illness or weather changes
  • Lifestyle factors
  • Psychosocial stressors
  • Pharmacological treatment
• Past medical history
  • Neurological disorders (e.g., epilepsy, neurocutaneous syndromes)
  • Prior head trauma
  • Sleep disorders
  • Mood disorders and/or anxiety disorders
  • Conditions associated with increased risk of urgent or life-threatening headache, e.g.:
    • Ventriculoperitoneal shunt
    • Sickle cell disease
    • Coagulopathy
    • Immune deficiency
    • Malignancy
    • Congenital heart disease
• Family history: headache or other neurological conditions
• Medication use
  • Psychostimulants
  • Oral analgesics
  • Medications associated with drug-induced increased intracranial hypertension ^[6]

Symptoms can be difficult to assess in young and/or preverbal children. Drawings of symptoms and/or caregiver-observed behaviors can help to infer severity and certain symptoms (e.g., photophobia). ^[5]

In adolescents, a HEADSS assessment can be used to screen for lifestyle factors that may exacerbate headaches. ^[2]

Focused examination ^[2][5][8]

• Pediatric vital signs
• Pediatric growth charts
• Pubertal stage assessment
• Complete neurological examination, including fundoscopy
• Palpation of the skull, temporomandibular joint, and sinuses
• Neck examination for pericranial muscle tenderness, trigger points, and range of motion
• Vision testing (e.g., with screening for refractive errors)
• Skin examination for neurocutaneous skin findings and signs of infectious meningitis (e.g., purpura, petechiae) ^[9]

For suspected urgent or life-threatening causes, initiate initial management for pediatric headache.

Approach ^[2][6]

• A primary headache disorder is diagnosed clinically if: ^[2][10]
  • Diagnostic criteria are met (see "Migraine in children" and "Tension-type headache in children"). ^[1]
  • No headache red flags are present, and neurological examination is normal.
  • No alternative cause accounts for the symptoms.
• Reserve diagnostics for individuals with headache red flags and/or features of a secondary cause.

For children with recurrent or chronic headaches, consider using a headache diary to improve diagnostic accuracy and guide management.

Neuroimaging ^[11]

• Indications
  • Abnormal neurological examination
  • Headache accompanied by seizure
  • Significant head trauma (see "Criteria for neuroimaging in children with blunt head trauma") ^[12]
  • Consider in children with headache red flags not listed above that suggest an intracranial process, e.g.:
    • Acute severe headache
    • Change in headache characteristics
• Modalities
  • MRI head with or without contrast is typically preferred in nonemergency settings.
  • CT head may be obtained for unstable patients or if rapid neuroimaging is needed, e.g.:
    • Significant head trauma ^[12]
    • Suspected intracranial hemorrhage or impending brain herniation ^[11]

Additional diagnostics ^[2][8][10]

In patients with headache red flags, tailor additional diagnostics to the suspected underlying cause.

• Lumbar puncture (LP) with CSF analysis: for suspected meningoencephalitis or pseudotumor cerebri syndrome
• Infectious disease testing (e.g., influenza testing, rapid strep testing)

Obtain neuroimaging before LP if risk factors for LP-associated brain herniation are present. ^[13][14][15]

Electroencephalography is not routinely indicated for the evaluation of recurrent headaches in children.

For suspected urgent or life-threatening causes, initiate initial management for pediatric headache.

Increased ICP is a potential complication of many urgent or life-threatening causes of pediatric headache and may require ICP management in addition to condition-specific management.

Consider abusive head trauma in children with severe injuries and/or unexplained injuries of any severity. ^[30]

Rhinosinusitis and vision-related headaches are frequently overdiagnosed. If suspected, thoroughly evaluate for other causes of headaches.

In addition to disease-specific therapies, consider the following measures for general management of headache symptoms. ^[5]

• Suspected life-threatening or urgent causes: See "Initial management of headache in children."
• Initiate symptomatic management as necessary.
  • Pain: ibuprofen, acetaminophen (see "Nonopioid oral analgesia in children")
  • Nausea and/or vomiting: ondansetron, dopamine antagonists (see "Antiemetics in children")
• Counsel on nonpharmacological measures that may reduce headache, including:
  • Nutrition (e.g., not skipping meals)
  • Regular exercise
  • Sleep hygiene
• Children with primary headache disorders: Screen for and manage associated comorbidities (e.g., anxiety, depression).
• Refer to specialists for:
  • Severe or highly disabling headaches
  • Diagnostic uncertainty or atypical features
  • Insufficient response to first-line treatments
  • Management of underlying cause of secondary headaches as necessary

Avoid aspirin in children < 15 years due to the risk of Reye syndrome. ^[38]