What is the diagnosis and treatment for a 7-year-old girl with recurrent headaches and vomiting for 6 months?

Diagnosis: Likely Primary Headache Disorder (Migraine or Abdominal Migraine)

This 7-year-old girl with 6 months of recurrent headaches and vomiting most likely has a primary headache disorder, specifically migraine or abdominal migraine, and should be treated with NSAIDs (ibuprofen 400-800 mg) plus antiemetics for acute episodes, with consideration for prophylactic therapy if attacks occur ≥2 days per month. 1, 2

Diagnostic Approach

Red Flag Assessment

First, determine if any red flags are present that would indicate a potentially life-threatening secondary headache requiring urgent neuroimaging 3, 2:

• Absence of red flags suggests primary headache: If the child has a normal neurological examination, no progressive worsening, no awakening from sleep due to headache, no morning-only headaches with severe vomiting, and no focal neurological symptoms, primary headache is most likely 3, 4, 2
• Red flags requiring immediate imaging: First or worst headache ever, recent onset with increasing severity, occipital location, awakening from sleep, morning-only headache with severe vomiting, altered consciousness, focal neurological signs, or abnormal neurological examination 4, 2

Distinguishing Primary Headache Types

Migraine characteristics 5:

• Recurrent moderate-to-severe unilateral pulsating headache lasting 4-72 hours
• Nausea/vomiting, photophobia, and phonophobia
• Worsens with routine physical activity
• Strong family history of migraine strengthens diagnosis 1

Abdominal migraine characteristics 1:

• Recurrent episodes of midline abdominal pain lasting 1-72 hours
• Complete wellness between episodes (stereotypic pattern)
• Associated with nausea, vomiting, anorexia, or pallor
• Strong family history of migraine
• More common in children than adults

Tension-type headache (less likely with vomiting) 5:

• Bilateral, mild-to-moderate pressing/tightening quality
• Lacks nausea/vomiting and photophobia/phonophobia
• Not aggravated by routine activity

Neuroimaging Decision

Neuroimaging is NOT indicated if 3, 6:

• Neurological examination is completely normal
• No red flags are present
• Pattern consistent with primary headache
• Studies show <1% of neurologically normal children with recurrent headache have clinically significant findings on MRI 3

MRI brain with and without contrast is indicated if 3, 5:

• Any red flags present
• Abnormal neurological examination
• Signs of increased intracranial pressure
• Atypical presentation or diagnostic uncertainty
• Nearly all children with brain tumors have accompanying neurological signs or symptoms 3

Treatment Strategy

Acute Episode Management

First-line acute treatment 1, 2:

• Ibuprofen 400-800 mg every 6 hours (maximum 2.4 g/day) for moderate-to-severe episodes 3, 2
• Ondansetron 8 mg sublingual/oral every 4-6 hours for nausea/vomiting 1
• Only ibuprofen and sumatriptan are proven significantly more effective than placebo in pediatric populations 2

Alternative acute treatments if NSAIDs fail 3:

• Naproxen sodium 275-550 mg every 2-6 hours (maximum 1.5 g/day)
• Aspirin 650-1,000 mg every 4-6 hours (maximum 4 g/day)

For severe episodes not responding to NSAIDs 3:

• Consider migraine-specific therapy (triptans), though evidence in children is limited
• Non-oral routes of administration if vomiting is prominent

Prophylactic Treatment Indications

Consider prophylaxis if 1:

• Attacks occur ≥2 days per month causing significant disability
• Despite optimized acute treatment, quality of life is impaired

First-line prophylactic agent 1:

• Propranolol: Most effective, with 75% achieving complete symptom cessation
• Alternative options include amitriptyline or topiramate

Non-Pharmacological Management

Essential components 1:

• Maintain headache/abdominal pain diary to identify triggers and monitor treatment effectiveness
• Regular exercise (40 minutes three times weekly) as effective as some medications for prevention
• Identify and avoid triggers through diary review

Common Pitfalls to Avoid

• Over-imaging: Neuroimaging in neurologically normal children with recurrent headache has a yield of only ~10%, with most findings being incidental and not requiring intervention 6
• Missing abdominal migraine: In children presenting primarily with vomiting and abdominal pain, consider abdominal migraine if there is complete wellness between stereotypic episodes and strong family history 1
• Medication overuse: If headaches occur ≥15 days/month with regular analgesic use ≥15 days/month for ≥3 months, medication-overuse headache must be considered 5
• Misdiagnosing "sinus headache": Approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) that can mimic sinusitis 3