From the Guidelines
For a 6-year-old with headache and nausea, the most appropriate initial approach is to start with a thorough history and physical examination to determine the cause, as recommended by the American College of Radiology 1 and supported by the Nature Reviews Neurology 1. This approach is crucial in identifying potential red flags that may indicate a more serious underlying condition. The history should include questions about headache characteristics, associated symptoms, recent illnesses, trauma, and family history of migraines. A complete neurological examination should be performed, including assessment of vital signs, such as blood pressure and temperature, and evaluation for signs of increased intracranial pressure like papilledema.
Key points to consider in the initial evaluation include:
- Headache characteristics, such as location, severity, and duration
- Associated symptoms, such as nausea, vomiting, and photophobia
- Recent illnesses or trauma
- Family history of migraines or other headaches
- Red flags, such as severe headache, worsening symptoms, early morning headaches with vomiting, neurological deficits, neck stiffness, or altered mental status
For mild symptoms, acetaminophen (Tylenol) at 10-15 mg/kg every 4-6 hours (not exceeding 5 doses in 24 hours) can be used for pain relief, as suggested by the American Family Physician 1. Additionally, ensuring the child stays hydrated and rests in a quiet, dark room can help alleviate symptoms. If nausea is significant, ondansetron (Zofran) 2 mg for children weighing 8-15 kg or 4 mg for those weighing over 15 kg can be considered.
It is essential to note that neuroimaging studies, such as CT or MRI, should only be considered when a secondary headache disorder is suspected, as recommended by the Nature Reviews Neurology 1. The yield of brain MRI is generally low in children with primary headaches, and incidental findings are common 1. Therefore, a thorough clinical evaluation should be performed before considering neuroimaging studies.
From the Research
Evaluation of Headache and Nausea in a 6-Year-Old
- The diagnosis and management of headache disorders, including those in pediatric patients, involve determining whether the headache is primary or secondary 2.
- Primary headache disorders are categorized into four groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders 2.
- Secondary headache disorders are due to an underlying medical condition and are classified according to their cause, such as vascular, neoplastic, infectious, or intracranial pressure/volume causes 2.
- Patients presenting with headache, including children, should be evaluated for symptoms or signs that suggest an urgent medical problem, such as an abrupt onset or neurologic signs 2.
Treatment Options for Headache
- Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine 2.
- Migraine-specific treatments, such as triptans, may be considered for patients who do not respond to initial treatments, but their use in pediatric patients should be carefully evaluated due to potential adverse effects 2.
- Other acute treatments, such as gepants and lasmiditan, may also be effective for migraine treatment, but their safety and efficacy in children are not well established 2.
Considerations for Pediatric Patients
- The evaluation and treatment of headache disorders in pediatric patients, including those with nausea, require careful consideration of the potential causes and the selection of appropriate treatments 2.
- The use of medications, such as triptans, in pediatric patients should be approached with caution due to potential adverse effects and the lack of established safety and efficacy in this population 2.