From the Guidelines
The workup for pediatric headache should begin with a thorough history and physical examination to identify potential causes and red flags, as recommended by the most recent study 1. Start by assessing headache characteristics (location, quality, severity, duration, frequency), associated symptoms (nausea, vomiting, visual changes), triggers, and relieving factors. Perform a complete neurological examination including fundoscopic exam to check for papilledema. Red flags warranting urgent evaluation include:
- Sudden onset severe headache
- Early morning headaches with vomiting
- Positional headaches
- Headaches worsening with Valsalva maneuvers
- Abnormal neurological findings
- Headaches in children under age 3 First-line imaging is not necessary for typical recurrent headaches with normal neurological exams, but MRI brain (preferred over CT to avoid radiation) should be considered with concerning features, as suggested by 1 and 1. Laboratory testing may include CBC, metabolic panel, and inflammatory markers if systemic illness is suspected. For migraine management, consider acetaminophen (15mg/kg/dose) or ibuprofen (10mg/kg/dose) for acute treatment. For frequent migraines, preventive options include amitriptyline (starting at 0.25-0.5 mg/kg/day), topiramate (starting at 0.5-1 mg/kg/day), or propranolol (0.5-1 mg/kg/day divided twice daily). Non-pharmacological approaches including adequate hydration, regular sleep, stress management, and trigger avoidance should be emphasized. Headache diaries help identify patterns and triggers. Referral to neurology is appropriate for complex, refractory, or concerning headaches. It is essential to note that the diagnosis and management of migraine should follow a step-by-step approach, including recording medical history, applying diagnostic criteria, considering differential diagnoses, examining the patient to exclude other causes, and using neuroimaging only when a secondary headache disorder is suspected, as outlined in 1.
From the Research
Workup for Pediatric Headache
The workup for pediatric headache involves a detailed history, physical and neurologic examinations, and diagnostic evaluation. The following are key components of the workup:
- A thorough understanding of the approach to the pediatric headache patient is essential to ensure appropriate diagnosis, evaluation, and management 2
- Clinical presentations and classification schema of multiple primary and secondary headache types in children are discussed using the International Headache Criteria (IHCD-3) as a guide 3
- The American Academy of Neurology (AAN) guidelines recommend against routine lab studies, lumbar puncture, electro-encephalogram (EEG), or neuroimaging in patients with no headache red flags by history and a normal neurologic examination 2
Diagnostic Evaluation
The diagnostic evaluation of pediatric headache patients includes:
- History and physical examination are the major tools for differentiating primary headache disorders from symptomatic headaches caused by defined pathologies 4
- Identification of "red flags" and "relatively red flags" that raise suspicion of intracranial pathology, which should prompt neuroimaging 4
- Regular clinical reevaluations should be warranted, even if neuroimaging is normal 4
Treatment Modalities
The treatment modalities for pediatric headache include: