Management of Headaches in a 15-Year-Old
Begin with a complete neurological examination including vital signs with blood pressure, cranial nerve assessment, fundoscopic examination, motor/sensory testing, cerebellar function, gait, and mental status to identify red flags that distinguish benign primary headaches from life-threatening secondary causes. 1
Initial Assessment: Red Flag Screening
The evaluation must identify specific warning signs that mandate immediate intervention versus benign primary headaches:
Critical red flags requiring emergent neuroimaging:
- Sudden severe "thunderclap" or "worst headache of life" presentation 1, 2
- Any abnormal neurological findings on examination 1
- Altered mental status or decreased level of consciousness 2
- Focal neurological signs (ataxia, hemiparesis, papilledema, cranial nerve palsies) 2
- Headache that awakens from sleep or worsens with Valsalva maneuver 2, 3
- Progressive worsening of headache severity or frequency 1, 3
- Occipital location (statistically associated with serious disease in children) 1, 2
- Recent head trauma 2
Key examination components:
- Blood pressure measurement is mandatory, as hypertension indicates increased intracranial pressure 1
- Fundoscopic examination is essential—papilledema indicates increased intracranial pressure and requires immediate action 1
- Do not skip fundoscopy; this is a common pitfall 1
Diagnostic Algorithm
If neurological examination is completely normal and no red flags present:
- Primary headaches (migraine or tension-type) are most likely 1
- Neuroimaging has very low yield (<1% clinically significant findings) and is NOT indicated 1, 2
- 94% of children with brain tumors have abnormal neurological findings at diagnosis 1
If ANY abnormal neurological finding or red flag present:
- Emergent neuroimaging is mandatory 1
- MRI without contrast is preferred for non-emergent evaluation (superior for tumors, stroke, parenchymal abnormalities) 1, 2
- CT without contrast for acute evaluation if concerned about hemorrhage 1, 2
Treatment Based on Diagnosis
For Mild to Moderate Primary Headache (Migraine or Tension-Type):
First-line acute treatment:
- NSAIDs: Ibuprofen 400-800 mg every 6 hours (max 2.4 g/day) 4, 5
- Naproxen sodium 275-550 mg every 2-6 hours (max 1.5 g/day) 4
- Combination analgesics containing caffeine 4, 5
- Do not use acetaminophen alone—it is ineffective as monotherapy for migraine 4, 2
For Moderate to Severe Migraine or Poor Response to NSAIDs:
Migraine-specific therapy:
- Triptans (sumatriptan, rizatriptan, zolmitriptan) eliminate pain in 20-30% of patients by 2 hours 4, 5
- Gepants (rimegepant, ubrogepant) eliminate headache in 20% of patients at 2 hours 5
- Lasmiditan (5-HT1F agonist) is safe in patients with cardiovascular risk factors 5
For migraine with prominent vomiting:
- Use non-oral routes of administration 4, 2
- Non-oral triptan with antiemetic 2
- Metoclopramide or prochlorperazine for nausea and synergistic analgesia 4
Critical Medication Pitfalls to Avoid:
- Avoid opioids (meperidine, butorphanol) and butalbital-containing compounds—they cause medication overuse headache, dependency, and rebound headaches 4, 2
- Limit acute treatment to no more than twice weekly to prevent medication overuse headache 2
- Triptans should be avoided in patients with cardiovascular disease due to vasoconstrictive properties 5
When to Consider Preventive Therapy:
Indications for prophylaxis:
- ≥2 headaches per week 3
- Chronic migraine pattern 3
- Preventive options reduce migraine by 1-3 days per month relative to placebo and include antihypertensives, antiepileptics (topiramate), antidepressants, and CGRP monoclonal antibodies 3, 5