What is the management approach for headaches in a 5-year-old child?

Management of Headaches in a 5-Year-Old Child

For a 5-year-old with headaches, start with ibuprofen at 10 mg/kg as first-line acute treatment, and consider bed rest alone for short-duration attacks before any medication. 1, 2

Initial Assessment Priorities

Before treating, you must distinguish primary from secondary headaches through focused evaluation:

• Red flags requiring immediate imaging: occipital location, inability to describe pain quality, focal neurological signs (ataxia, hemiparesis, papilledema), thunderclap onset, fever with neurological signs 1, 3
• Most common causes at this age: viral upper respiratory infections (39%), sinusitis (9%), migraine (18%), with serious pathology rare (<5%) 3
• Neuroimaging is NOT indicated for primary headaches with normal neurological examination 1, 4

Acute Treatment Algorithm

First-Line: Non-Pharmacological and Ibuprofen

• Bed rest alone may suffice for short-duration attacks in young children—try this first 1
• Ibuprofen 10 mg/kg is the recommended first-line medication when pharmacotherapy is needed 1, 2
• Give medication at the earliest onset of headache for maximum efficacy 1

Second-Line: Alternative Routes if Oral Fails

• If nausea/vomiting prevents oral administration, use rectal or nasal routes 2
• For adolescents 12-17 years, domperidone can address nausea, though it won't prevent vomiting 1

Important Cautions

• Avoid opioids and butalbital entirely—they cause medication overuse headache and dependency 1, 5
• Triptans have NOT been proven effective in children under 12 due to high placebo response in trials 1
• For adolescents 12-17 years, nasal sumatriptan or zolmitriptan are most effective triptan formulations if NSAIDs fail 1

Preventive Treatment Considerations

If headaches occur frequently (≥2 disabling days per month despite optimized acute treatment):

• Non-pharmacological first: Progressive muscle relaxation and biofeedback have proven efficacy 2
• Pharmacological options (if non-pharmacological fails): propranolol, amitriptyline, or topiramate, though effectiveness is not proven in pediatric trials 1
• Referral to specialist is indicated if acute medication provides insufficient relief 1

Essential Lifestyle Modifications

Address these predisposing factors with parents and teachers:

• Sleep: Ensure adequate and consistent sleep patterns 1, 5
• Meals: Prevent hypoglycemia with regular meals 5, 2
• Hydration: Maintain adequate fluid intake 5
• Stress management: Address school pressure and emotional triggers 2
• Physical activity: Regular exercise, though avoid during active attacks 5

Family and School Education

Clinical management requires active involvement from parents and teachers 1:

• Parents provide more reliable symptom descriptions than young children 1
• Educate about trigger avoidance (emotional stress, sensory stimulation, sleep disruption) 2
• Explain that migraine attacks in children are often shorter, bilateral (2/3 of cases), and frontal rather than unilateral as in adults 1, 2
• Gastrointestinal symptoms (nausea, vomiting, abdominal pain) are commonly prominent 1

Common Pitfalls to Avoid

• Don't routinely order labs, EEG, or neuroimaging without red flags—this exposes children to unnecessary radiation and anxiety 1, 4
• Don't dismiss as psychological due to lack of imaging findings—migraine is extensively underdiagnosed in pediatrics 2
• Don't use acetaminophen/paracetamol as first-line—it has less efficacy than ibuprofen 1
• Don't allow frequent acute medication use—this leads to medication overuse headache 1, 5