What is the recommended approach for evaluating and managing headaches in children?

Evaluation of Headache in Children

The evaluation of pediatric headache should be driven by a thorough neurological examination to identify red flags; neuroimaging is NOT indicated for primary headaches with normal examination, as the diagnostic yield is less than 1%. 1

Initial Clinical Assessment

Essential History Components

• Headache characteristics: onset (sudden vs gradual), frequency, duration, location, quality, severity, and temporal pattern 2, 3
• Associated symptoms: vomiting (especially morning vomiting), visual changes, fever, neurological symptoms, or changes in mental status 4, 5
• Timing patterns: headaches that awaken the child from sleep, occur exclusively in the morning, or are worsening in frequency/severity 4
• Family history: particularly for migraine, as this supports primary headache diagnosis 2
• Medication and substance use: including over-the-counter medications and potential withdrawal 3

Mandatory Physical Examination Elements

• Vital signs with blood pressure measurement: hypertension can indicate increased intracranial pressure or other serious pathology 6
• Fundoscopic examination: essential for detecting papilledema, which indicates increased intracranial pressure 6
• Complete cranial nerve assessment: abnormalities suggest secondary causes 6
• Motor and sensory testing: focal deficits are red flags 6
• Cerebellar function and gait evaluation: ataxia or coordination problems warrant imaging 6
• Mental status assessment: altered consciousness requires immediate evaluation 6
• Head circumference: if concerns for increased intracranial pressure exist, particularly in younger children 6

Critical Red Flags Requiring Neuroimaging

Absolute Indications for Imaging

• Papilledema on fundoscopy 6
• Any abnormal neurological finding on examination 6
• Sudden severe "thunderclap" headache (worst headache ever) 1, 6
• Progressive neurological symptoms or focal deficits 1
• Headache awakening child from sleep 4
• Morning headache with severe vomiting 4
• Occipital location (rare in children and warrants caution) 1
• Recent onset with increasing severity or frequency 4
• Altered mental status or seizures 1

Special Populations Requiring Lower Threshold for Imaging

• Sickle cell disease patients: higher risk for acute CNS events including stroke, posterior reversible encephalopathy syndrome, and subarachnoid hemorrhage 1
• Post-trauma headache: if neurological signs develop, headaches worsen, or associated with vomiting 1
• Suspected infection: meningitis, encephalitis, sinusitis with complications, or mastoiditis 1

Imaging Algorithm

For Primary Headache (Normal Examination, No Red Flags)

• No imaging is indicated: neuroimaging yield is less than 1% for clinically significant findings in children with normal examination 1, 6
• Common misdiagnosis pitfall: "sinus headache" is frequently misdiagnosed in pediatric migraineurs, as 62% have cranial autonomic symptoms (rhinorrhea) mimicking sinusitis 1

For Secondary Headache (Red Flags Present)

• MRI without contrast is the preferred initial study: superior sensitivity for tumors, stroke, and parenchymal abnormalities 1
• Add contrast if noncontrast MRI is abnormal: particularly for suspected tumor, infection, or vascular abnormalities 1
• Include susceptibility-weighted imaging (SWI) or gradient echo (GRE): for detecting hemorrhage or remote trauma 1

For Acute Emergency Presentations

• CT without contrast: appropriate for acute evaluation when immediate assessment needed, particularly for suspected hemorrhage 1
• MRI/MRA preferred over CT/CTA: when stroke or hemorrhage detected and further vascular evaluation needed 1
• CTA indicated: if arterial dissection suspected and MRI unavailable 1

For Specific Secondary Causes

• Suspected increased intracranial pressure or tumor: MRI without and with contrast 1
• Pseudotumor cerebri (idiopathic intracranial hypertension): MRI with MRV to evaluate venous sinus abnormalities 1
• Chiari I malformation: sagittal T2-weighted MRI of craniocervical junction with optional phase-contrast CSF flow study 1
• Venous sinus thrombosis: MRV is preferred; CTV is alternative with high sensitivity/specificity 1
• Infection-related headache: MRI with and without contrast 1

Key Clinical Pearls

Primary Headache Characteristics

• Migraine: most common primary headache (~55% of pediatric headaches), often with cranial autonomic symptoms 1
• Tension-type headache: second most common (~30% of cases) 1
• Diagnosis is clinical: based on International Headache Society criteria, not imaging 2, 3

Brain Tumor Considerations

• 94% of children with brain tumors have abnormal neurological findings at diagnosis 1
• 60% have papilledema at presentation 1
• Other common findings: gait disturbance, abnormal reflexes, cranial nerve abnormalities, altered sensation 1
• Nearly all children with intracranial tumors have symptoms beyond isolated headache 1

Common Pitfalls to Avoid

• Do not skip fundoscopic examination: essential for detecting increased intracranial pressure 6
• Do not order routine neuroimaging without red flags: yield is less than 1% and exposes children to unnecessary radiation or sedation 1, 6
• Do not dismiss occipital headache: rare in children and requires diagnostic caution 1
• Do not assume "sinus headache": consider migraine with cranial autonomic symptoms first 1
• Do not use EEG routinely: limited value in headache evaluation unless seizures suspected 3, 4
• Do not use conventional arteriography as first-line: invasive and requires skilled angiographer; reserve for specific indications after noninvasive imaging 1