From the Guidelines
Red flags for headaches in teenagers include sudden onset of severe headache, headaches that wake the teen from sleep, headaches that worsen with position changes or Valsalva maneuvers, headaches accompanied by neurological symptoms, persistent vomiting, fever, neck stiffness, or altered mental status. These red flags are crucial in identifying potential life-threatening conditions such as meningitis, brain tumor, intracranial hemorrhage, or increased intracranial pressure 1. The most recent and highest quality study, published in 2021 in Nature Reviews Neurology, emphasizes the importance of suspecting migraine without aura in individuals with recurrent moderate to severe headache, particularly if pain is unilateral and/or pulsating, and when the person has accompanying symptoms such as photophobia, phonophobia, nausea, and/or vomiting 1.
When evaluating a teenager with a headache, it is essential to consider the following key points:
- Sudden onset of severe headache
- Headaches that wake the teen from sleep
- Headaches that worsen with position changes or Valsalva maneuvers
- Headaches accompanied by neurological symptoms, such as vision changes, weakness, numbness, or speech difficulties
- Persistent vomiting, fever, neck stiffness, or altered mental status
- Headaches that progressively worsen over time
- Headaches that don't respond to over-the-counter medications
- New headaches in a teen with cancer or immunosuppression
- Headaches following head trauma
The American Academy of Neurology suggests that neuroimaging should be considered only in patients with migraine who have atypical headache patterns or neurologic signs 1. The U.S. Headache Consortium guidelines do not recommend neuroimaging if the patient is not at higher risk of a significant abnormality than the general population or if the results of the study would not change the management of the headache 1.
In the context of real-life clinical medicine, it is crucial to prioritize caution and consider the potential risks and benefits of neuroimaging. If a teenager experiences any of the red flags, they should be evaluated by a healthcare provider immediately, as these symptoms could indicate serious conditions that require prompt attention 1. Parents should not hesitate to seek emergency care if these warning signs are present, as early diagnosis and treatment of serious neurological conditions can significantly improve outcomes.
From the Research
Red Flags for Headache in Adolescents
The following are red flags for headache in adolescents:
- Signs and symptoms of dangerous causes, such as secondary headaches due to underlying conditions like infections, trauma, vascular disorders, substance use/withdrawal, and psychiatric conditions 2
- Abnormal neurologic examination findings 2
- Presence of red flags by history, which may necessitate diagnostic testing, such as imaging studies or laboratory tests 3, 2
Evaluation of Headache in Adolescents
A comprehensive evaluation of headache in adolescents should include:
- A thorough history and physical examination 4, 5, 3, 2
- Neurologic evaluation and charting of the temporal pattern of the headache 4, 5
- Evaluation of psychosocial factors, as psychological factors are important in all forms of adolescent headache 4, 5
- Laboratory testing tailored to the specific headache syndrome, although routine lab studies are not recommended in patients with no headache red flags by history and a normal neurologic examination 2