What is the recommended treatment approach for pediatric patients presenting with headaches, considering their medical history and potential underlying conditions?

Pediatric Headache Management

Initial Clinical Assessment

The cornerstone of pediatric headache evaluation is a thorough neurological examination to identify red flags; neuroimaging is NOT indicated for primary headaches with normal examination, as the diagnostic yield is less than 1% for clinically significant findings. 1, 2

Essential History Components

• Document headache characteristics systematically: age of onset, duration of episodes, frequency, pain quality (pulsating vs. pressure), location, intensity, and aggravating/relieving factors 2
• Obtain detailed family history of migraine, as it has a strong genetic component and is frequently positive in pediatric patients 2
• Identify accompanying symptoms: nausea, vomiting, photophobia, phonophobia, visual changes, or neurological deficits 2
• Use headache diaries to track patterns, triggers, and treatment responses over time 2

Critical Neurological Examination Elements

• Measure vital signs including blood pressure, as hypertension can indicate increased intracranial pressure or other serious pathology 1
• Perform fundoscopic examination to detect papilledema, which indicates increased intracranial pressure 1
• Complete cranial nerve assessment, motor and sensory testing, cerebellar function, gait evaluation, and mental status assessment 1
• Measure head circumference if there are concerns about increased intracranial pressure in younger children 1

Red Flags Requiring Immediate Neuroimaging

Any of the following warrant urgent imaging with MRI without contrast (preferred) or CT without contrast (if immediate assessment needed): 1, 2

• Sudden severe "thunderclap" headache (worst ever headache) suggesting subarachnoid hemorrhage 1
• Progressive neurological symptoms or focal deficits 1, 2
• Papilledema on fundoscopic examination 1
• Altered mental status or seizures 1
• Occipital location (rare in children and warrants caution) 1
• Headache worsened by Valsalva maneuver (suggests Chiari malformation) 1
• Any abnormal neurological finding on examination 1

Common Pitfall to Avoid

Do not skip fundoscopic examination, as it is essential for detecting increased intracranial pressure; 60% of children with brain tumors have papilledema 1

Imaging Algorithm

When Imaging IS Indicated

• MRI without contrast is the preferred initial study for secondary headache evaluation, with superior sensitivity for tumors, stroke, and parenchymal abnormalities 3, 1, 2
• CT without contrast is appropriate for acute evaluation when immediate assessment is needed, particularly for suspected hemorrhage 3, 1
• MRI with sagittal T2-weighted sequence of the craniocervical junction is specifically indicated when Chiari I malformation is suspected 1
• MRV is indicated if venous sinus thrombosis is suspected 3

When Imaging is NOT Indicated

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 1, 2, 4

Primary Headache Diagnosis

Migraine Without Aura

Diagnosis requires at least 5 attacks, with each attack lasting 4-72 hours, and at least 2 of the following: 2

• Unilateral location
• Pulsating quality
• Moderate or severe intensity
• Aggravation by routine physical activity

Critical Diagnostic Pearl

Approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) that can mimic sinusitis; consider migraine first rather than "sinus headache" 1

Acute Treatment

First-Line Therapy

Ibuprofen should be used as first-line treatment for acute headache in children and adolescents 2

Adolescent-Specific Options

Adolescents may be considered for triptans: sumatriptan/naproxen combination, zolmitriptan, sumatriptan, rizatriptan, or almotriptan 2

Important Safety Note

Sumatriptan is NOT recommended for use in patients younger than 18 years of age, as safety and effectiveness in pediatric patients have not been established; postmarketing reports document serious adverse reactions including stroke, visual loss, and myocardial infarction in pediatric patients 5

Preventive Treatment

Preventive treatment should be considered for children with frequent or disabling headaches, or with overuse of acute medication: 2

• Amitriptyline combined with cognitive-behavioral therapy may be effective 2
• Topiramate may be effective 2
• Propranolol may be effective 2

Lifestyle and Education

Educate patients and families on: 2

• Lifestyle factors and migraine triggers
• Avoiding overuse of acute medication (to prevent medication overuse headache)
• Maintaining headache calendars to evaluate treatment effectiveness

Secondary Headache Considerations

Brain Tumors

Brain tumors account for only 2.6% of acute headache presentations, and 94% of children with brain tumors have abnormal neurological findings at diagnosis 1

Other Serious Causes

• Pseudotumor cerebri (idiopathic intracranial hypertension) typically presents in overweight females with papilledema 1
• Arterial dissection or stroke, particularly in children with sickle cell disease 1
• Venous sinus thrombosis 1
• Infection-related headaches (meningitis, encephalitis, mastoiditis) require MRI with and without IV contrast 3

Follow-Up Strategy

Use headache calendars to evaluate effectiveness and adverse events; when results are suboptimal, review the diagnosis, treatment strategy, dosage, and adherence 2