What is the appropriate treatment for a child experiencing headaches?

Treatment of Pediatric Headaches

For acute headache treatment in children, use ibuprofen as first-line therapy; in adolescents, consider adding triptans (sumatriptan/naproxen combination, nasal zolmitriptan, or rizatriptan ODT) if ibuprofen alone is insufficient. 1

Initial Diagnostic Approach

Before initiating treatment, perform a focused assessment to distinguish primary from secondary headaches:

• Obtain vital signs including blood pressure (hypertension may indicate increased intracranial pressure or serious pathology) 1, 2
• Complete neurological examination including cranial nerves, fundoscopic examination for papilledema, motor/sensory testing, cerebellar function, gait, and mental status 2
• Identify red flags that mandate neuroimaging: abnormal neurological findings, papilledema, severe/"worst ever" headache, progressive symptoms, altered mental status, occipital location, or age <6 years 2, 3, 4

Critical point: Neuroimaging has <1% yield in children with normal examination and no red flags, so avoid routine imaging in primary headaches 1, 2, 5

Acute Pharmacologic Treatment Algorithm

First-Line Treatment

• Ibuprofen for all children with acute headache pain 1
• Counsel early treatment at headache onset for maximum efficacy 1
• Avoid opioids entirely—they are not recommended for pediatric headache 1

Second-Line for Adolescents (if ibuprofen insufficient)

• Sumatriptan/naproxen oral combination 1
• Nasal triptans: zolmitriptan or sumatriptan 1
• Oral triptans: rizatriptan ODT or almotriptan 1

Treatment Modifications

• If one triptan fails, try another triptan or NSAID-triptan combination 1
• For rapid pain escalation, use non-oral triptan formulations (nasal sprays) 1
• For significant nausea/vomiting, add antiemetic or use non-oral triptan 1

Preventive Treatment Considerations

Discuss preventive therapy with families when headaches are frequent or disabling, but transparently acknowledge that placebo was as effective as medication in many pediatric trials 1

Evidence-Based Preventive Options

• Amitriptyline combined with cognitive behavioral therapy 1
• Topiramate (counsel about teratogenic effects; ensure effective contraception and folate supplementation in adolescent females) 1
• Propranolol 1

Critical Safety Warnings

Analgesic Overuse

Counsel families about rebound headache risk from analgesic overuse 1—this is a common pitfall that can transform episodic headache into chronic daily headache. For chronic post-traumatic headache, consider analgesic overuse as a contributory factor and refer for multidisciplinary evaluation 1

Avoid Unproven Therapies

Do not use 3% hypertonic saline outside research settings—insufficient evidence supports its use for acute pediatric headache 1

When to Escalate Care

• Severe headache with risk factors or worsening symptoms: Consider head CT to evaluate for intracranial complications requiring intervention 1
• Acutely worsening headache during observation: Obtain emergent neuroimaging 1
• Chronic refractory headache: Refer for multidisciplinary evaluation including assessment for medication overuse, vestibular dysfunction, sleep disorders, and psychological factors 1

Lifestyle and Trigger Management

Advise on lifestyle modifications and trigger avoidance as foundational therapy for all children with recurrent headaches 1—this includes adequate sleep, regular meals, hydration, and stress management, though these are adjunctive to pharmacologic treatment when acute pain requires intervention.