What is the best course of action for an 11-year-old female patient experiencing recurrent morning headaches and vomiting, occurring a few times a month?

Urgent Neuroimaging Required Before Treatment

This 11-year-old with recurrent morning headaches and vomiting requires immediate brain imaging (MRI preferred) to rule out posterior fossa tumor or other causes of increased intracranial pressure before any treatment is initiated. 1

Red Flags Demanding Urgent Evaluation

This presentation contains multiple concerning features that mandate neuroimaging:

• Morning-predominant headaches with vomiting are classic for increased intracranial pressure, particularly posterior fossa masses in children 2
• Vomiting upon waking suggests overnight accumulation of intracranial pressure that peaks in the morning when lying supine 2
• The pattern of "a few times a month" does not exclude serious pathology—brain tumors can present with episodic symptoms initially 1

Specific Diagnostic Approach

Before considering migraine or other primary headache disorders, obtain:

• MRI brain with and without contrast (preferred over CT for posterior fossa evaluation) to exclude:

  • Posterior fossa tumor (medulloblastoma, ependymoma, pilocytic astrocytoma) 2
  • Hydrocephalus 3
  • Chiari malformation 2
  • Other structural lesions causing intermittent increased intracranial pressure 1

• Fundoscopic examination to assess for papilledema, which indicates elevated intracranial pressure 2

Alternative Diagnosis to Consider: Cyclic Vomiting Syndrome

If neuroimaging is normal, consider cyclic vomiting syndrome (CVS), which shares characteristics with migraine and presents with:

• Episodes of nausea and vomiting lasting 1-5 days 4
• Asymptomatic periods between episodes 4
• Strong association with migraine pathophysiology 4

CVS management includes:

• Prophylactic therapy with antimigraine medications (antidepressants, antiepileptics) showing >70% reduction or remission of symptoms 4
• Trigger avoidance and supportive care during acute episodes 4

If Primary Migraine is Confirmed After Imaging

Only after excluding secondary causes, migraine treatment in children ≥12 years follows adult guidelines:

• Acute treatment: Combine a triptan with an NSAID or paracetamol as first-line therapy 5
• Preventive therapy indicated if attacks occur ≥2 times per month producing disability lasting ≥3 days 6, 1
• First-line preventive options include propranolol 80-240 mg/day or amitriptyline 30-150 mg/day 6, 1

Critical Pitfall to Avoid

Never assume recurrent morning headaches with vomiting in a child are "just migraines" without neuroimaging. 2 The consequences of missing a posterior fossa tumor or hydrocephalus are catastrophic—delayed diagnosis leads to irreversible neurological damage or death. Even with a history of "episodic" symptoms, structural lesions can present intermittently as intracranial pressure fluctuates. 3