What is the appropriate management for a 10-year-old patient presenting with headache and vomiting?

Management of Headache and Vomiting in a 10-Year-Old

In a 10-year-old presenting with headache and vomiting, immediately assess for life-threatening causes (meningitis, intracranial hemorrhage, brain tumor, hydrocephalus) through focused history and neurological examination, then treat the most likely cause—viral illness or migraine—with appropriate supportive care and antiemetics. 1, 2

Initial Assessment and Red Flags

The first priority is rapid identification of dangerous causes requiring urgent intervention. Look specifically for these red flag features that indicate serious pathology 3, 2:

• Altered mental status or decreased level of consciousness 3
• Severe or "worst headache of life" presentation 4, 2
• Occipital location of headache (statistically associated with serious disease in children) 2
• Inability of the child to describe the quality of pain 2
• Focal neurological signs (ataxia, hemiparesis, papilledema, cranial nerve palsies) 2
• Headache that awakens from sleep or worsens with Valsalva maneuver 4
• Bilious or bloody vomiting 3
• Fever with toxic appearance, nuchal rigidity, or signs of sepsis 1, 3
• Recent head trauma 4

Differential Diagnosis by Likelihood

Most Common Causes (>80% of cases)

Viral upper respiratory infection with fever is the leading cause, accounting for 57% of acute headache presentations in children (39% viral URI, 9% sinusitis, 9% streptococcal pharyngitis) 2. The second most common is primary migraine (18% of cases) 2.

Life-Threatening Causes Requiring Immediate Action

Though uncommon, these must be excluded 1, 2:

• Bacterial meningitis or viral meningitis (9% of acute headache presentations) 2
• Intracranial hemorrhage including subarachnoid hemorrhage (1.3%) 2
• Brain tumor particularly posterior fossa tumors (2.6%) 2
• Hydrocephalus or VP shunt malfunction (2%) 2

Diagnostic Approach

Physical Examination Priorities

Perform a complete neurological examination focusing on 4:

• Vital signs including blood pressure (hypertension can cause headache) 4
• Fundoscopic examination for papilledema 4
• Nuchal rigidity assessment 4
• Focal neurological deficits (cranial nerves, motor, sensory, cerebellar function) 2

All children with surgically remediable conditions had clear and objective neurological signs on examination 2. If the neurological examination is completely normal and no red flags are present, serious pathology is unlikely.

Neuroimaging Indications

Do not routinely image children with primary headache and normal neurological examination 4. The yield of neuroimaging in pediatric headache is very low, with <1% having clinically relevant findings 4.

MRI brain without contrast is the preferred initial imaging modality when indicated 4. Specific indications include 4:

• Abnormal neurological examination findings 4
• Headache with progressive worsening, increasing frequency, or increasing severity 4
• Headache associated with persistent vomiting 4
• Sudden severe "thunderclap" headache (use non-contrast CT head for speed to detect subarachnoid hemorrhage) 4
• Suspected intracranial infection (use MRI with and without IV contrast) 4

Treatment Algorithm

For Suspected Viral Illness (Most Common)

Supportive care with hydration and simple analgesics 4:

• Ibuprofen (NSAID) as first-line treatment 4
• Acetaminophen can be used but is less effective alone; more effective when combined with aspirin and caffeine 4
• Ondansetron 0.2 mg/kg oral (maximum 4 mg) for persistent vomiting preventing oral intake 3

For Suspected Migraine

NSAIDs are first-line treatment for pediatric migraine 4. Specifically:

• Ibuprofen, naproxen sodium, or aspirin 4
• Combination of acetaminophen-aspirin-caffeine for enhanced efficacy 4

For severe migraine with prominent vomiting, use non-oral routes 4:

• Non-oral triptan with antiemetic for severe nausea/vomiting 4
• Ketorolac (parenteral NSAID) for severe migraine in emergency settings 4

Avoid opioids and butalbital-containing compounds as they lead to medication overuse headache, dependency, and rebound headaches 4.

For Dehydration from Vomiting

Stop oral intake and provide IV hydration if the child has signs of dehydration or cannot tolerate oral fluids 3. Assess hydration status carefully as severe dehydration is a red flag requiring immediate intervention 3.

Critical Pitfalls to Avoid

• Do not miss meningitis: Any fever with headache, vomiting, and altered mental status requires immediate evaluation for meningitis 1, 2
• Do not overlook occipital headache: This location is statistically associated with serious underlying disease in children 2
• Do not use acetaminophen alone for migraine: It is ineffective as monotherapy 4
• Do not create medication overuse headache: Limit acute treatment to no more than twice weekly 4
• Do not order routine neuroimaging: Imaging is not indicated with normal examination and no red flags 4

When to Escalate Care

Immediate emergency evaluation or neurosurgical consultation is required for 1, 2:

• Any focal neurological signs (ataxia, hemiparesis, papilledema) 2
• Altered mental status or decreased consciousness 3
• Signs of increased intracranial pressure 1
• Suspected subarachnoid hemorrhage (thunderclap headache) 4