What is the initial management for a 7-year-old presenting with headache and vomiting?

Management of Headache and Vomiting in a 7-Year-Old

Begin with immediate assessment for life-threatening red flags, then provide supportive care with hydration and ibuprofen for presumed viral illness or migraine, while avoiding neuroimaging unless red flags are present.

Immediate Red Flag Assessment

First, rapidly screen for features requiring urgent intervention:

• Altered mental status or decreased level of consciousness indicates potential meningitis, intracranial hemorrhage, or increased intracranial pressure 1
• Severe or "worst headache of life" presentation suggests possible intracranial hemorrhage or other catastrophic pathology 1
• Fever with headache and vomiting requires immediate evaluation to rule out meningitis 1
• Focal neurological signs (ataxia, hemiparesis, papilledema, cranial nerve palsies) mandate urgent neuroimaging 1
• Occipital location is statistically associated with serious underlying disease in children 1
• Headache awakening child from sleep or worsening with Valsalva suggests increased intracranial pressure 1, 2
• Recent head trauma necessitates urgent intervention 1

Physical Examination Priorities

Perform a focused neurological examination including:

• Vital signs assessment (fever suggests infection) 1
• Fundoscopic examination for papilledema 1
• Nuchal rigidity assessment (meningeal signs) 1
• Evaluation for focal neurological deficits 1
• Assessment of hydration status 3

Treatment Algorithm for Non-Emergency Cases

If no red flags are present, proceed with symptomatic management:

First-Line Treatment

• Ibuprofen is the appropriate first-line analgesic for pediatric headache 4
• Ensure adequate hydration as dehydration commonly accompanies vomiting 3
• Small, frequent volumes (e.g., 5 mL every minute) if vomiting is prominent 5

For Persistent Vomiting

• Ondansetron 0.2 mg/kg oral (maximum 4 mg) is indicated for children unable to take oral fluids due to persistent vomiting 3
• Non-oral routes (such as intranasal triptans with antiemetics) may be necessary for severe migraine with prominent vomiting in appropriate age groups 1

What NOT to Use

• Avoid acetaminophen alone as it is ineffective as monotherapy for migraine 1
• Avoid opioids and butalbital-containing compounds due to risk of medication overuse headache, dependency, and rebound headaches 5, 1
• Limit acute treatment to no more than twice weekly to prevent medication overuse headache 5, 1

Neuroimaging Decision

Neuroimaging is NOT routinely indicated for children with normal neurological examination and no red flags 5, 1

When imaging IS indicated:

• MRI brain without contrast is the preferred initial imaging modality 5, 1
• Indications include any red flag features listed above 5, 1

Critical Pitfalls to Avoid

• Do not miss meningitis: Any fever with headache, vomiting, and altered mental status requires immediate evaluation 1
• Do not dismiss occipital headache: This location carries higher risk of serious pathology in children 1
• Do not order routine neuroimaging: It is not indicated with normal examination and no red flags 5, 1
• Do not create medication overuse: Limit acute treatment frequency 1

Most Likely Diagnoses in This Age Group

While most headaches in children presenting to emergency settings are benign, the differential includes:

• Viral illness (most common cause of acute vomiting and headache) 3, 6
• Primary migraine (second most common after viral illness) 6
• Acute gastroenteritis (leading cause of acute vomiting) 3