What is the appropriate evaluation and treatment for a child presenting with a headache?

Evaluation and Treatment of Pediatric Headache

Initial Clinical Assessment

The evaluation of a child with headache begins with a complete neurological examination including vital signs with blood pressure, cranial nerve assessment, fundoscopic examination, motor/sensory testing, cerebellar function, gait, and mental status—this examination determines whether neuroimaging is needed and distinguishes benign primary headaches from life-threatening secondary causes. 1

Essential History Components

• Headache characteristics: Age of onset, duration of episodes, frequency, pain quality (pulsating vs. pressure), intensity, location, and whether aggravated by physical activity 2
• Associated symptoms: Nausea, vomiting, photophobia, phonophobia, visual changes, or aura symptoms 2
• Temporal pattern: Time of day, awakening from sleep, exclusively morning headaches, or progressive worsening 3
• Family history: Migraine has strong genetic component and is frequently positive in pediatric patients 2
• Triggers and relieving factors: Stress, sleep patterns, dietary factors, medication use 2

Critical Red Flags Requiring Immediate Neuroimaging

• Thunderclap headache (sudden severe "worst ever" headache) suggests subarachnoid hemorrhage 1
• Papilledema on fundoscopy indicates increased intracranial pressure 1
• Focal neurological deficits or progressive neurological symptoms 1
• Altered mental status or seizures 1
• Occipital location (rare in children and warrants caution) 1
• Headache worsened by Valsalva maneuver (suggests Chiari malformation) 1
• Awakening from sleep due to headache or exclusively morning headaches with severe vomiting 3

Diagnostic Algorithm

For Children with Normal Neurological Examination and No Red Flags

Neuroimaging is NOT indicated—the diagnostic yield is less than 1% for clinically significant findings in this population. 1 The diagnosis rests on clinical criteria:

• Migraine without aura requires at least 5 attacks lasting 4-72 hours, with at least 2 of: unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine physical activity 2
• Tension-type headache accounts for approximately 30% of pediatric headaches 1
• Approximately 55% of children with headache have migraine, 30% have tension-type, and only 10% have secondary causes 4

For Children with ANY Abnormal Neurological Finding or Red Flag

MRI without contrast is the preferred imaging modality for non-emergent evaluation, with superior sensitivity for tumors, stroke, and parenchymal abnormalities compared to CT. 1

• CT without contrast is appropriate only for acute evaluation when immediate assessment is needed, particularly for suspected hemorrhage or thunderclap headache 1
• MRI with sagittal T2-weighted sequence of the craniocervical junction is specifically indicated when Chiari malformation is suspected 1
• MRV is indicated if venous sinus thrombosis is suspected (especially with mastoiditis or sphenoid sinusitis) 1
• MRI with IV contrast is preferred if intracranial infection is suspected, though CT may be performed before lumbar puncture in emergency settings 4, 1

Treatment Approach

Acute Treatment

Ibuprofen is first-line medication for acute pain relief at 10 mg/kg every 6-8 hours (maximum 400 mg per dose). 1, 2

• Acetaminophen is an alternative at 15 mg/kg every 4-6 hours (maximum 650 mg per dose) 1
• For adolescents aged 12-17 years: Nasal spray formulations of sumatriptan and zolmitriptan are most effective; other options include sumatriptan/naproxen, rizatriptan, or almotriptan 1, 2
• Domperidone can be used for nausea in adolescents 1

Preventive Treatment

Consider preventive therapy for children with frequent or disabling headaches, or with overuse of acute medication. 2

• Amitriptyline combined with cognitive-behavioral therapy may be effective 2
• Topiramate or propranolol are alternative preventive options 1, 2
• Use headache calendars to evaluate effectiveness and adverse events 2

Lifestyle Modifications

Educate patients and families on lifestyle factors, migraine triggers, and avoiding overuse of acute medication. 2

Common Pitfalls to Avoid

• Do not skip fundoscopic examination—it is essential for detecting papilledema and increased intracranial pressure 1
• Do not diagnose "sinus headache" without considering migraine first—approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) that mimic sinusitis, leading to frequent misdiagnosis 1
• Do not order routine neuroimaging without red flags—94% of children with brain tumors have abnormal neurological findings at diagnosis, and nearly all have symptoms beyond isolated headache 1
• Do not dismiss the importance of blood pressure measurement—hypertension can indicate increased intracranial pressure or other serious pathology 1

When to Refer to Specialist

• Insufficient pain relief from acute medication 1
• Need for preventive therapy initiation or adjustment 1
• Suboptimal results requiring review of diagnosis, treatment strategy, dosage, and adherence 2