Management of Random Headache and Vomiting in a 9-Year-Old
First assess for red flags requiring immediate neuroimaging: altered mental status, focal neurological deficits (ataxia, hemiparesis, papilledema, cranial nerve palsies), headache awakening from sleep or worsening with Valsalva, occipital location, recent head trauma, or fever with neck stiffness—if any are present, obtain MRI brain without contrast immediately. 1, 2
Initial Red Flag Assessment
Perform a focused neurological examination looking specifically for:
- Altered consciousness or decreased level of consciousness 1
- Focal neurological signs: ataxia, hemiparesis, papilledema, or cranial nerve palsies 1
- Occipital headache location (statistically associated with serious underlying disease in children) 1
- Fever with headache and vomiting (suggests meningitis until proven otherwise) 1
- Recent head trauma 1
- Headache characteristics: awakens from sleep, worsens with Valsalva, progressively worsening, or "worst headache of life" 2, 1
If any red flags are present, obtain MRI brain without contrast as the preferred initial imaging modality. 2, 1 Neuroimaging is NOT routinely indicated with normal neurological examination and no red flags. 2, 1, 3
Diagnostic Approach for Benign Presentations
If neurological examination is normal and no red flags are present:
- Most likely diagnosis is primary headache (migraine or tension-type) or benign secondary headache (viral illness). 4, 3
- Viral gastroenteritis with associated headache accounts for the majority of acute headache-vomiting presentations in children. 5, 6
- Primary headaches (migraine) represent 21.8-66.3% of pediatric ED headache presentations, while life-threatening causes represent only 2-15.3%. 4
Treatment Algorithm
For Suspected Viral Illness or Mild Migraine:
Start with ibuprofen (10 mg/kg, maximum 800 mg) as first-line therapy, as it is one of only two medications proven significantly more effective than placebo in pediatric headache. 4, 1
- Administer as early as possible during the attack for maximum efficacy 2, 1
- Ensure adequate hydration with oral rehydration solution 5, 6
- Limit ibuprofen use to no more than 2 days per week to prevent medication-overuse headache 1, 7
For Severe Migraine with Prominent Vomiting:
Consider non-oral routes when significant nausea or vomiting is present. 1, 7
- Intranasal sumatriptan (5-20 mg) is the only other medication proven significantly more effective than placebo in pediatric populations 4, 7
- Ondansetron (0.2 mg/kg oral or 0.15 mg/kg IV, maximum 4 mg) is indicated for persistent vomiting preventing oral intake 5
- IV metoclopramide (10 mg) plus IV ketorolac (30 mg) provides rapid relief for severe attacks requiring emergency treatment 7, 1
Critical Medications to Avoid:
Never use opioids or butalbital-containing compounds in pediatric headache, as they lead to medication-overuse headache, dependency, and rebound headaches. 1, 7
Acetaminophen alone is ineffective as monotherapy for migraine. 2, 1
Common Pitfalls to Avoid
- Do not miss meningitis: Any fever with headache, vomiting, and altered mental status requires immediate evaluation for central nervous system infection 1
- Do not overlook occipital headache location: This is statistically associated with serious underlying disease in children and warrants lower threshold for neuroimaging 1
- Do not order routine neuroimaging: It is not indicated with normal examination and no red flags, as life-threatening causes represent only 2-15.3% of presentations 2, 1, 4
- Do not create medication-overuse headache: Limit all acute treatments to no more than 2 days per week 1, 7
- Do not assume viral gastroenteritis without careful consideration of other causes: Regular review in early phases ensures fulminant illnesses are not overlooked 6
When to Initiate Preventive Therapy
If headaches occur more than twice weekly despite optimized acute treatment, initiate preventive therapy rather than increasing frequency of acute medications. 2, 1, 7