What are the causes and management of headaches in children?

Causes of Headache in Children

Headaches in children are predominantly caused by primary headache disorders (migraine and tension-type headache) or upper respiratory infections with fever, while serious secondary causes like brain tumors are rare and nearly always accompanied by abnormal neurological findings.

Primary Headache Causes

Migraine is the most frequent cause of acute and recurrent headaches in children, accounting for approximately 18% of acute presentations and being the predominant cause of recurrent headaches 1, 2. Key features include:

• Paroxysmal episodes with symptom-free intervals between attacks 3
• May present with hemicranial pain, though bilateral frontal pain is more common in younger children 3
• Associated symptoms include nausea, vomiting, abdominal pain, and photophobia 3
• Approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) that can mimic sinusitis 4
• Psychological stress is the most common precipitating factor in school-age children 3

Tension-type headache represents 10-25% of non-migraine headaches in children 5.

Secondary Headache Causes

Infectious Causes (Most Common Secondary Etiology)

Upper respiratory tract infections with fever account for 57% of acute headache presentations to emergency departments 2:

• Viral upper respiratory tract infection: 39% 2
• Acute sinusitis: 9% 2
• Streptococcal pharyngitis: 9% 2
• Viral meningitis: 9% 2

Serious Intracranial Causes (Rare but Critical)

Brain tumors are uncommon but critical to identify 4, 2:

• Account for only 2.6% of acute headache presentations 2
• 94% of children with brain tumors have abnormal neurological findings at diagnosis 4, 6
• 60% have papilledema on fundoscopic examination 4
• Other neurological signs include gait disturbance, abnormal reflexes, cranial nerve deficits, and altered sensation 4
• Occipital headache location is a red flag, as it is rare in children and warrants diagnostic caution 4, 2

Other serious secondary causes include 2, 7:

• Intracranial hemorrhage: 1.3% 2
• Ventriculoperitoneal shunt malfunction: 2% 2
• Pseudotumor cerebri (idiopathic intracranial hypertension): typically in overweight females with papilledema 4
• Chiari I malformation: presents with occipital headache worsened by Valsalva maneuver 4
• Arterial dissection or stroke: particularly in children with sickle cell disease 4
• Venous sinus thrombosis 4
• Inflammatory conditions: acute disseminated encephalomyelitis, multiple sclerosis, vasculitis 7
• Epilepsy: postictal headache accounts for 1.3% 2

Clinical Red Flags Requiring Immediate Evaluation

Critical warning signs that distinguish benign from life-threatening causes 6, 8:

• Papilledema on fundoscopic examination (indicates increased intracranial pressure) 4, 6
• Abnormal neurological findings on examination 4, 6
• Sudden severe "thunderclap" or "worst ever" headache 6, 8
• Occipital location of headache 4, 2
• Inability to describe the quality of head pain 2
• Progressive neurological symptoms or focal deficits 6
• Altered mental status or seizures 6
• Signs of meningitis (fever, neck stiffness) 8

Diagnostic Algorithm

For children with normal neurological examination and no red flags:

• Neuroimaging is NOT indicated, as the diagnostic yield is less than 1% for clinically significant findings 4, 6
• Primary headache diagnosis (migraine or tension-type) is most appropriate 1

For children with ANY abnormal neurological finding or red flag:

• MRI without contrast is the preferred imaging modality for non-emergent evaluation, with superior sensitivity for tumors, stroke, and parenchymal abnormalities 4, 6
• CT without contrast is appropriate for acute/emergent evaluation when immediate assessment is needed, particularly for suspected hemorrhage 6
• MRI/MRA is preferred over CT/CTA when vascular evaluation is needed 6

Common Pitfalls to Avoid

• Do not diagnose "sinus headache" without considering migraine first, as cranial autonomic symptoms are common in pediatric migraineurs and frequently lead to misdiagnosis 4
• Do not skip fundoscopic examination, as it is essential for detecting papilledema and increased intracranial pressure 6, 8
• Do not order routine neuroimaging without red flags, as the yield is less than 1% in children with normal examination 4, 6
• Do not assume normal imaging excludes all pathology—clinical correlation is necessary, particularly for conditions like idiopathic intracranial hypertension 8
• All children with surgically remediable conditions have clear and objective neurological signs—isolated headache without examination findings is almost never a brain tumor 2