What is the appropriate management for a child presenting with a headache?

Management of Pediatric Headache

Most children presenting with headache have benign primary headaches (migraine or tension-type) that require only clinical diagnosis and symptomatic treatment with ibuprofen, while neuroimaging is NOT indicated unless red flags are present on history or examination, as the diagnostic yield is less than 1% in children with normal neurological findings. 1, 2

Initial Clinical Assessment Algorithm

Step 1: Obtain Targeted History

• Age of onset, duration, frequency, and pain characteristics (unilateral vs bilateral, pulsating vs pressing quality, intensity) 2
• Aggravating factors: worsening with Valsalva maneuver suggests Chiari malformation; worsening with routine physical activity suggests migraine 1, 2
• Relieving factors and accompanying symptoms: nausea, vomiting, photophobia, phonophobia 2
• Family history of migraine (strong genetic component, frequently positive in pediatric patients) 2
• Cranial autonomic symptoms: rhinorrhea and nasal congestion occur in 62% of pediatric migraineurs and are commonly misdiagnosed as "sinus headache" 1

Step 2: Perform Complete Neurological Examination

This is the most critical step for risk stratification. 1

• Vital signs with blood pressure measurement (mandatory to detect hypertension indicating increased intracranial pressure) 1
• Fundoscopic examination (papilledema present in 60% of children with brain tumors; indicates increased intracranial pressure) 1
• Comprehensive cranial nerve assessment 1
• Motor and sensory testing, cerebellar function, gait evaluation 1
• Mental status assessment 1
• Head circumference if concerns for increased intracranial pressure exist 1

Red Flags Requiring Immediate Neuroimaging

Any of the following mandate emergent evaluation: 1, 3, 4

• Abnormal neurological examination findings (94% of children with brain tumors have abnormal neurological findings at diagnosis) 1
• Papilledema on fundoscopy 1
• Thunderclap headache (sudden severe "worst ever" headache suggesting subarachnoid hemorrhage) 1
• Progressive neurological symptoms or focal deficits 1
• Altered mental status or seizures 1
• Occipital location (rare in children and warrants diagnostic caution) 1
• Headache worsened by Valsalva maneuver (suggests Chiari malformation) 1
• Recent onset severe headache (<6 months) that is progressive 3
• Headache awakening child from sleep or occurring exclusively in morning with severe vomiting 3, 4
• Age <6 years 3
• New headache in immunocompromised child 3

Imaging Algorithm When Red Flags Present

MRI without contrast is the preferred initial study for non-emergent evaluation, with superior sensitivity for tumors, stroke, Chiari malformation, and parenchymal abnormalities compared to CT. 1, 2

CT without contrast is appropriate for acute/emergent evaluation when immediate assessment is needed, particularly for suspected hemorrhage (thunderclap headache). 1, 2

MRI with sagittal T2-weighted sequence of craniocervical junction is specifically indicated when Chiari I malformation is suspected. 1

MRV is indicated if venous sinus thrombosis is suspected (can occur with mastoiditis or sphenoid sinusitis). 5

Management for Primary Headaches (Normal Examination, No Red Flags)

Acute Treatment

Ibuprofen is first-line treatment for acute headache in children and adolescents. 2

For adolescents, consider sumatriptan/naproxen combination, zolmitriptan, sumatriptan, rizatriptan, or almotriptan. 2

Preventive Treatment Indications

Consider preventive therapy for: 2

• Frequent or disabling headaches
• Overuse of acute medication

Effective preventive options include: 2

• Amitriptyline combined with cognitive-behavioral therapy
• Topiramate
• Propranolol

Non-Pharmacological Management

• Educate patients and families on lifestyle factors, migraine triggers, and avoiding medication overuse 2
• Implement headache diaries for diagnosis confirmation and treatment monitoring 2

Common Pitfalls to Avoid

Do NOT skip fundoscopic examination—it is essential for detecting increased intracranial pressure and papilledema. 1

Do NOT order routine neuroimaging without red flags—the yield is <1% in children with normal examination and no concerning history. 1, 2, 6

Do NOT diagnose "sinus headache" without considering migraine first—cranial autonomic symptoms (rhinorrhea, nasal congestion) are common in 62% of pediatric migraineurs and frequently lead to misdiagnosis. 1

Do NOT dismiss severe headache based solely on normal imaging—other causes like idiopathic intracranial hypertension (pseudotumor cerebri, typically in overweight females with papilledema) may require further evaluation including lumbar puncture. 1

Do NOT order routine laboratory tests, lumbar puncture, or EEG in patients with no red flags and normal neurological examination. 6

Secondary Headache Considerations

Brain tumors account for only 2.6% of acute headache presentations, and nearly all have symptoms beyond isolated headache. 1

Other serious secondary causes to consider: 1

• Arterial dissection or stroke (particularly in sickle cell disease)
• Venous sinus thrombosis
• Idiopathic intracranial hypertension
• Intracranial infections (meningitis, encephalitis)

Follow-up Strategy

Use headache calendars to evaluate treatment effectiveness and adverse events. 2

When results are suboptimal, review the diagnosis, treatment strategy, dosage, and medication adherence. 2