Evaluation and Management of Recurrent Headaches with Vomiting and Fever in a 7-Year-Old
This child requires urgent evaluation for bacterial meningitis given the combination of headache, vomiting, and fever—even though the fever was transient—and should receive immediate empiric antibiotics if any signs of meningeal irritation or systemic illness are present, without waiting for imaging or lumbar puncture. 1, 2
Immediate Clinical Assessment
Critical Red Flags to Evaluate NOW
The presence of fever with headache and vomiting occurring together raises immediate concern for meningococcal disease or bacterial meningitis, which can be fatal within 24 hours if untreated 1. You must immediately assess for:
- Meningeal signs: Neck stiffness (present in 82% of pediatric bacterial meningitis), Kernig sign, Brudzinski sign 3
- Altered mental status: Drowsiness, irritability, confusion (present in 13-56% of cases) 3
- Rash: Petechiae or purpura suggesting meningococcal disease (present in 39-51% of pediatric cases) 3, 1
- Neurological deficits: Focal signs, seizures (occur in 10-56% at presentation) 3
- Vital signs: Tachycardia suggesting septicemia, blood pressure for shock 1
Critical pitfall: Clinical signs have poor sensitivity—neck stiffness is only 51% sensitive, and the classic triad of fever/neck stiffness/altered mental status occurs in only 41-51% of cases 3. Absence of these findings cannot rule out bacterial meningitis 3.
If ANY Concerning Features Are Present
Administer parenteral antibiotics immediately (ceftriaxone 50-100 mg/kg IV, max 2g) without waiting for imaging or lumbar puncture, as most meningococcal deaths occur within the first 24 hours 1, 2. Add dexamethasone 0.15 mg/kg to reduce mortality and neurological sequelae 2.
Diagnostic Algorithm
Step 1: Determine Need for Neuroimaging Before Lumbar Puncture
Obtain non-contrast head CT immediately before lumbar puncture if any of the following are present 3, 2:
- Focal neurological signs
- Papilledema on fundoscopic exam
- Decreased level of consciousness or altered mental status
- Signs of increased intracranial pressure
Do NOT delay antibiotics while obtaining imaging—treat first, image second 1, 2.
Step 2: Lumbar Puncture
If CT is negative or not indicated, proceed immediately to lumbar puncture 2. In children <12 months (and probably <18 months), lumbar puncture should be performed even without obvious meningeal signs, as presentation is often nonspecific 3.
Expected CSF findings in bacterial meningitis 2:
- Neutrophilic pleocytosis
- CSF/blood glucose ratio <0.4
- Elevated protein >45 mg/dL
- Elevated opening pressure >25 cm H₂O
Step 3: If Meningitis/Encephalitis Is Ruled Out
If the child appears well, has normal neurological examination, and meningitis is excluded, consider primary headache disorder (migraine or tension-type headache, which account for 55% and 30% of pediatric headaches respectively) 3.
Neuroimaging Indications for Recurrent Headaches
MRI brain without and with IV contrast is the preferred imaging modality for non-emergent evaluation of recurrent headaches 3. However, neuroimaging has very low yield in children with primary headaches—only <1% have clinically relevant findings 3.
Specific Indications for MRI in This Case
Given the recurrent pattern with vomiting, obtain MRI if any of the following are present 3, 4, 5:
- Age <6 years (this child is 7, borderline)
- Headaches awakening child from sleep
- Exclusively morning headaches with severe vomiting (suggests increased intracranial pressure)
- Progressive worsening in severity or frequency
- Occipital location (rare in primary headaches, warrants caution)
- Abnormal neurological examination
- No family history of migraine
- Change in headache pattern
Specific MRI sequences to request 3:
- Sagittal T2-weighted sequence of cranio-cervical junction (to evaluate for Chiari I malformation, which presents with headache worsened by Valsalva)
- MRV if pseudotumor cerebri suspected (can present with recurrent headaches and vomiting)
Management Strategy
If Bacterial Meningitis/Encephalitis Confirmed
- Continue IV antibiotics for 10-14 days 2
- Monitor for complications: seizures, hydrocephalus, abscess formation 3
- Consider repeat MRI if clinical deterioration 3
If Primary Headache Disorder (Migraine Most Likely)
- Acute treatment: Ibuprofen 10 mg/kg (most effective in pediatric studies) 5
- Prophylaxis: Consider if headaches significantly impact quality of life (>3-4 episodes/month affecting school/activities)
- Identify and avoid triggers
- Ensure adequate hydration and regular sleep schedule
Common Pitfalls to Avoid
Never assume viral illness based on transient fever—early meningococcal disease is clinically indistinguishable from self-limiting viral illnesses 1
Never delay antibiotics for imaging or LP if bacterial meningitis is suspected—mortality increases dramatically with treatment delays 1, 2
Do not rely on absence of fever to rule out serious pathology—fever may be intermittent or absent in CNS infections 3
Do not perform routine neuroimaging in children with typical migraine features and normal neurological examination—yield is <1% and exposes child to unnecessary sedation risk 3
Do not order EEG for headache evaluation—it has no diagnostic or prognostic value 3, 6