What is the management for a headache after a traumatic head injury in a 6-year-old child?

Management of Headache After Traumatic Head Injury in a 6-Year-Old

Treat the headache immediately with nonopioid analgesics—either ibuprofen or acetaminophen—as first-line therapy, while simultaneously assessing for red flags that would require emergent neuroimaging. 1, 2

Immediate Assessment and Risk Stratification

First, determine if this child requires emergent head CT imaging. Children with severe or worsening headache after mild traumatic brain injury (mTBI) carry a 1.9% risk of intracranial complications when Glasgow Coma Scale (GCS) scores are 13-15. 1, 3

Obtain head CT immediately if any of these red flags are present: 2, 3

• Severe or progressively worsening headache
• Headache associated with vomiting
• Loss of consciousness at time of injury
• Altered mental status
• Any neurological deficits on examination
• GCS score 13 or below

If the headache is mild to moderate without red flags, proceed directly to pharmacological management while continuing observation. 1, 2

Acute Pharmacological Management

Administer nonopioid analgesics as the cornerstone of treatment: 1, 2, 4

• Ibuprofen: Age-appropriate dosing (typically 10 mg/kg every 6-8 hours, maximum 400 mg per dose for a 6-year-old)
• Acetaminophen: Age-appropriate dosing (typically 15 mg/kg every 4-6 hours, maximum 650 mg per dose for a 6-year-old)

Critical counseling point: Explicitly warn parents about analgesic overuse headache. Using pain medication more than 2-3 days per week can cause rebound headaches that worsen the overall condition and complicate recovery. 1, 2, 3 This is a common pitfall that transforms an acute problem into a chronic one.

Never prescribe opioids for post-traumatic headache—they are not recommended and worsen outcomes. 1, 2, 4

Do not use 3% hypertonic saline outside of research settings, despite limited evidence suggesting possible immediate benefit. 1, 2, 4

Monitoring and Follow-Up Strategy

Provide clear return precautions to parents: 2, 5

• Return immediately if headache worsens or becomes severe
• Return if new symptoms develop (vomiting, confusion, vision changes, weakness)
• Return if headache persists beyond 10 days despite treatment 5
• Return if fever develops 5

Schedule follow-up at 2-4 weeks to reassess headache trajectory. 2, 4 At this visit, determine if the headache is resolving (acute post-traumatic headache) or persisting beyond 2 months (which would classify as chronic post-traumatic headache). 1, 6

Management of Persistent or Chronic Headache (Beyond 2 Months)

If headache persists beyond 2 months, recognize this as chronic post-traumatic headache requiring a different approach. 1, 4 The mechanism becomes multifactorial at this point, and aggressive early treatment is critical to prevent permanent chronicity. 6

Refer for multidisciplinary evaluation and treatment, which should include: 1, 2, 4

• Reassessment for analgesic overuse as a contributory factor
• Evaluation by pediatric neurology or headache specialist
• Assessment for comorbid sleep disturbance, mood disorders, or cognitive dysfunction

Consider additional interventions based on associated symptoms: 1, 4

• If vestibular symptoms or dizziness are present: Refer to vestibular rehabilitation program 1, 4
• If sleep problems emerge: Implement sleep hygiene measures first, then refer to sleep specialist if problems persist 1, 4
• If cognitive dysfunction is present: Evaluate within the context of ongoing headache, as pain itself can disrupt cognitive processing 1, 4

Common Pitfalls to Avoid

Do not dismiss severe headache as "just a concussion symptom" without imaging—this may miss life-threatening intracranial complications. 3 The evidence shows a nearly 2% risk of intracranial injury even with seemingly mild presentations. 1, 3

Do not allow analgesic overuse to develop. This is the most common preventable cause of chronic post-traumatic headache in children. 1, 2 Limit acute medication use to no more than 2-3 days per week. 2, 3

Do not delay aggressive treatment if headache persists. Early intervention prevents "windup" and chronicity—once chronic patterns establish, they become significantly more difficult to interrupt. 6

Non-Pharmacological Adjuncts

Encourage supportive measures alongside medication: 2

• Adequate hydration
• Rest in a quiet, dark environment
• Cool compresses to the forehead for symptomatic relief

Implement proper sleep hygiene to facilitate recovery, as adequate sleep has been shown to facilitate healing after TBI. 1, 4

Prognosis Considerations

Be aware that post-traumatic headache is extremely common in children—studies show up to 83% of children experience headache after brain concussion, with 27% developing chronic headache. 7 Age is a risk factor, with younger children potentially at higher risk. 7 The cumulative incidence over one year can reach 91%, with headaches often persisting across the entire first year. 8

Headache severity correlates with other symptom domains and neurocognitive outcomes. Children with significant headache complaints show 5-fold higher total symptom scores and worse objective neurocognitive testing, suggesting they may benefit from specialized follow-up care. 9