What is the initial management for a teenager presenting with headache and sore throat in the emergency department (ED)?

Initial Management of Headache and Sore Throat in Teenagers in the Emergency Department

The initial management for a teenager presenting with headache and sore throat in the emergency department should focus on symptomatic relief with ibuprofen or paracetamol, thorough assessment for serious underlying causes, and targeted antibiotic therapy only when bacterial infection is strongly suspected based on clinical criteria. 1

Initial Assessment

History and Physical Examination

• Assess for "red flags" that might indicate serious illness requiring immediate intervention 1
• Evaluate headache characteristics (location, quality, severity, aggravating/alleviating factors) to distinguish between tension-type, migraine, or secondary headache 1
• For sore throat, use Centor criteria to assess likelihood of bacterial pharyngitis: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1
• Consider viral upper respiratory tract infection as the most common cause of acute headache with sore throat in teenagers 2, 3

Warning Signs Requiring Urgent Attention

• Occipital headache location, which has been statistically associated with serious underlying disease 2
• Inability of the patient to describe the quality of the head pain 2
• Focal neurological signs, altered mental status, or severe systemic symptoms 3
• Rapid onset or "worst headache of life" description 4

Diagnostic Approach

When to Consider Further Testing

• Routine neuroimaging is not indicated for typical headaches without concerning features 4
• Consider laboratory testing (rapid strep test, throat culture) when Centor score is 3-4 1
• Consider lumbar puncture if meningitis is suspected based on clinical presentation 3, 5

Common Diagnoses to Consider

• Viral upper respiratory infection (most common cause - approximately 39-57% of cases) 2, 5
• Streptococcal pharyngitis (approximately 9% of cases with headache and sore throat) 2
• Sinusitis (approximately 9-16% of cases) 2, 5
• Migraine (approximately 15-18% of cases) 2, 5
• Viral meningitis (approximately 5-9% of cases) 2, 5

Treatment Recommendations

First-Line Symptomatic Management

• Provide either ibuprofen or paracetamol for relief of acute sore throat and headache symptoms 1
• Ensure adequate hydration and rest 1
• Consider antiemetics if nausea or vomiting is present (associated with fewer revisits) 6

Antibiotic Therapy

• Antibiotics should not be used in patients with less severe presentation of sore throat (0-2 Centor criteria) 1
• For patients with 3-4 Centor criteria, consider discussing the modest benefits of antibiotics (1-2 days faster symptom resolution) against potential side effects 1
• If antibiotics are indicated, penicillin V is the first choice, twice or three times daily for 10 days 1

Special Considerations

• Patients with mild-moderate pain treated with acetaminophen alone or no medication have higher rates of return visits 6
• Corticosteroids can be considered in adult patients with more severe presentations of sore throat (3-4 Centor criteria) but are not routinely recommended 1

Disposition and Follow-up

Discharge Criteria

• Provide appropriate safety netting advice to patients who are self-managing 1
• Ensure patients know when to return (if symptoms worsen rapidly or significantly, do not improve over a specified time, or they become systemically very unwell) 1

Follow-up Recommendations

• Most cases of viral upper respiratory infections and uncomplicated headaches can be managed with follow-up as needed 3
• For patients prescribed antibiotics, consider follow-up to ensure resolution of symptoms 1