What are the current recommendations for managing a new onset headache in an 11-year-old child with a recent positive COVID-19 (Coronavirus Disease 2019) test, no other symptoms, stable vital signs, and no past medical history?

Management of New-Onset Headache in an 11-Year-Old with COVID-19

For a well-appearing 11-year-old with isolated headache, stable vitals, and positive COVID-19 test, outpatient management with symptomatic treatment and close monitoring is appropriate, but you must actively screen for warning signs of MIS-C or neurological complications that would require immediate hospitalization. 1

Initial Risk Stratification

The vast majority of children with COVID-19 present with mild symptoms and have excellent outcomes. 1 However, headache can represent either a benign symptom of acute COVID-19 or an early warning sign of more serious complications, particularly MIS-C or neurological involvement. 1

Key clinical context: MIS-C is temporally associated with SARS-CoV-2 infection, typically emerging 2-6 weeks after peak COVID-19 incidence in a geographic area, though it remains rare (approximately 2 per 200,000 individuals under 21 years). 1, 2

Immediate Assessment Required

Red Flags Requiring Hospital Admission

You must immediately hospitalize this child if ANY of the following are present: 1

• Neurologic changes: Altered mental status, confusion, encephalopathy, focal neurologic deficits, meningismus, or papilledema 1
• Abnormal vital signs: Tachycardia or tachypnea (even if currently stable, reassess frequently) 1
• Persistent fever: Temperature ≥38.0°C for ≥24 hours 1
• Additional systemic symptoms: Rash, conjunctivitis, abdominal pain, vomiting, diarrhea, or mucosal changes 1

Screening Laboratory Evaluation (Tier 1)

If the child appears well but you have any clinical concern, obtain: 1, 2

• Complete blood count with differential
• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
• Complete metabolic panel
• Consider: Troponin, BNP/NT-proBNP if any cardiac symptoms

Critical thresholds that mandate admission: 1

• CRP ≥10 mg/dl (marked elevation)
• Abnormal troponin or BNP levels
• Evidence of renal or hepatic injury

Outpatient Management Strategy

When Outpatient Care is Appropriate

Outpatient evaluation is reasonable for well-appearing children with stable vital signs when physical examination provides reassurance and close follow-up can be ensured. 1

Symptomatic Treatment

• Antipyretics: Acetaminophen or ibuprofen for headache and fever management 3
• Hydration: Ensure adequate fluid intake
• Rest: Encourage appropriate activity restriction

Mandatory Close Follow-Up

You must establish a clear follow-up plan with specific return precautions: 1

• Daily monitoring for development of fever, additional symptoms, or worsening headache
• Immediate return if any red flag symptoms develop (see above)
• Re-evaluation within 24-48 hours either in-person or via telehealth

Critical Pitfalls to Avoid

Do Not Miss MIS-C

Headache is specifically listed as an "additional feature" in the RCPCH case definition of MIS-C. 1 The key distinction is that isolated headache in an otherwise well child is likely benign, but headache with ANY additional systemic symptoms requires aggressive evaluation. 1

MIS-C warning signs to monitor: 1, 2

• Development of persistent fever (≥3 days)
• Gastrointestinal symptoms (abdominal pain, vomiting, diarrhea)
• Mucocutaneous findings (rash, conjunctivitis, oral changes)
• Edema of hands/feet
• Lymphadenopathy

Neurological Complications

There are increasing reports of neurological involvement in pediatric COVID-19, manifesting as severe headache, altered mental status, or cranial nerve palsies in select patients. 1 While rare, new-onset seizures have been reported as an acute presentation in previously healthy children with COVID-19. 4

If headache is severe, progressive, or associated with ANY neurological symptoms, consider: 1

• Lumbar puncture (after appropriate imaging if indicated)
• Brain imaging (CT or MRI)
• Immediate hospital admission

Timeline Considerations

Acute COVID-19 phase (current presentation): Most children have mild illness with excellent outcomes. 1, 5 Isolated headache is common and typically benign.

Post-infectious phase (2-6 weeks later): Remain vigilant for MIS-C development, which characteristically occurs weeks after initial infection. 1, 2 Ensure family understands to seek immediate care if new symptoms develop during this window.

Documentation and Safety Netting

Provide explicit written instructions to caregivers including: 1

• Specific symptoms requiring immediate return (fever, rash, abdominal pain, confusion, difficulty breathing)
• Expected duration of symptoms (typically 3-5 days for mild COVID-19)
• Follow-up appointment timing
• 24-hour contact information for concerns