What is the appropriate evaluation and management for a 6-year-old (six years old) child presenting with headaches for 6 days?

Evaluation and Management of a 6-Year-Old with 6 Days of Headaches

For a 6-year-old with headaches for 6 days, perform a complete neurological examination including vital signs with blood pressure, fundoscopic examination, cranial nerve assessment, motor/sensory testing, cerebellar function, and gait evaluation—if this examination is normal and no red flags are present, neuroimaging is NOT indicated as the diagnostic yield is less than 1%, and the headache is most likely a primary headache disorder (migraine or tension-type). 1

Initial Clinical Assessment

The evaluation must focus on identifying red flags that distinguish benign primary headaches from life-threatening secondary causes:

Critical Red Flags Requiring Immediate Neuroimaging 1, 2

• Age <6 years is itself a red flag requiring heightened vigilance 2
• Abnormal neurological examination findings
• Papilledema on fundoscopic examination (indicates increased intracranial pressure) 1
• Severe or "worst ever" headache
• Headache awakening child from sleep 3, 2
• Headache exclusively in morning with severe vomiting 3
• Occipital location (rare in children and warrants caution) 1
• Altered mental status or seizures 1
• Fever with headache 2
• Headache worse with Valsalva maneuver 1

Essential Examination Components 1

• Blood pressure measurement is mandatory (hypertension can indicate increased intracranial pressure) 1
• Fundoscopic examination is essential—do not skip this, as 60% of children with brain tumors have papilledema 1
• Complete cranial nerve assessment
• Motor and sensory testing
• Cerebellar function and gait evaluation
• Mental status assessment
• Head circumference measurement (relevant at age 6 if increased intracranial pressure suspected) 1

Diagnostic Algorithm

If Neurological Examination is NORMAL and No Red Flags 1, 4

• Neuroimaging is NOT indicated—the yield is <1% for clinically significant findings 1
• Diagnosis is most likely primary headache (migraine 21.8-66.3% or tension-type headache ~30% of pediatric headaches) 2, 1
• Current American Academy of Neurology guidelines recommend against routine lab studies, lumbar puncture, EEG, or neuroimaging in patients with normal examination 4

If ANY Abnormal Neurological Finding or Red Flag is Present 1, 5

• MRI without contrast is the preferred imaging modality for non-emergent evaluation, with superior sensitivity for tumors, stroke, and parenchymal abnormalities 1, 5
• CT without contrast is appropriate for acute evaluation when immediate assessment is needed, particularly for suspected hemorrhage or thunderclap headache 5, 1
• Note: 94% of children with brain tumors have abnormal neurological findings at diagnosis, and nearly all have symptoms beyond isolated headache 1

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 1
• Do not diagnose "sinus headache" without considering migraine first—62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) that mimic sinusitis 1
• Do not dismiss the significance of age <6 years—this age group requires heightened vigilance as it is itself a red flag 2

Management Based on Likely Diagnosis

For Primary Headache (Normal Examination, No Red Flags) 2

• Acute treatment: Ibuprofen is significantly more effective than placebo for headache relief in children 2
• Most headaches in the emergency/acute setting are due to benign conditions that are self-limiting or resolve with appropriate pharmacological treatment 2
• Consider viral illness as a common secondary cause if fever or systemic symptoms present 6

For Concerning Features Requiring Further Evaluation 5, 1

• If venous sinus thrombosis suspected (especially with mastoiditis or sphenoid sinusitis): MRV is indicated 5, 1
• If intracranial infection suspected: CT may be performed before lumbar puncture, but MRI with IV contrast is preferred if available 5
• If Chiari malformation suspected (occipital headache worse with Valsalva): MRI with sagittal T2-weighted sequence of craniocervical junction 1