What is the appropriate evaluation and management for an 11-year-old child presenting with headaches?

Evaluation and Management of Headaches in an 11-Year-Old Child

Initial Clinical Assessment

Begin with a thorough neurological examination including vital signs with blood pressure measurement, complete cranial nerve assessment, fundoscopic examination of the optic discs, motor and sensory testing, cerebellar function, gait evaluation, and mental status assessment to identify red flags that distinguish benign primary headaches from life-threatening secondary causes. 1

Essential History Components

• Obtain detailed headache characteristics: age of onset, duration of episodes (noting that attacks <1 hour are common in this age group), frequency, pain quality (pulsating vs. pressure-like), location, and intensity 2, 3
• Document aggravating factors (physical activity, Valsalva maneuver) and relieving factors 2
• Identify accompanying symptoms: nausea, vomiting, photophobia, phonophobia, visual changes, or cranial autonomic symptoms (rhinorrhea, nasal congestion) 2, 4
• Obtain family history of migraine, as it has a strong genetic component and is frequently positive in pediatric patients 2
• Assess for lifestyle factors, triggers, and psychosocial stressors 2, 5

Critical Red Flags Requiring Immediate Neuroimaging

• Papilledema on fundoscopic examination indicates increased intracranial pressure and requires emergent evaluation 1, 4
• Abnormal neurological findings on examination (focal deficits, gait disturbance, abnormal reflexes, cranial nerve abnormalities, altered sensation) 4, 1
• Sudden severe "thunderclap" or "worst ever" headache 1
• Progressive or worsening headache pattern 1
• Headache awakening the child from sleep or occurring exclusively in the morning with severe vomiting 5
• Altered mental status or seizures 1
• Occipital location (rare in children and warrants caution) 1
• Headache worsened by Valsalva maneuver (suggests Chiari malformation) 1

Diagnostic Algorithm

For Normal Neurological Examination Without Red Flags

Neuroimaging is NOT indicated, as the diagnostic yield for clinically significant findings is less than 1% in children with normal examination and no concerning history. 4, 1, 2

• Approximately 55% of pediatric headaches are migraine, 30% are tension-type, and only 10% are secondary causes 1
• Initiate a headache diary documenting frequency, duration, triggers, and associated symptoms 2, 1
• Provide reassurance and parental education about primary headache disorders 1

For Abnormal Neurological Findings or Red Flags

MRI of the brain without contrast is the preferred imaging modality for non-emergent evaluation, with superior sensitivity for tumors, stroke, and parenchymal abnormalities compared to CT. 1, 2

• CT without contrast is appropriate only for acute evaluation when immediate assessment is needed, particularly for suspected hemorrhage (thunderclap headache) 1
• If initial noncontrast MRI is abnormal, post-contrast imaging is usually indicated 4
• Consider MRV if venous sinus thrombosis is suspected (especially with mastoiditis or sphenoid sinusitis) 1
• Consider MRA if arterial dissection or stroke is suspected 1
• For suspected Chiari malformation, obtain MRI with sagittal T2-weighted sequence of the craniocervical junction 1

Primary Headache Diagnosis

Migraine Without Aura

• Requires at least 5 attacks, each lasting 4-72 hours (often shorter and bilateral in children this age) 2
• At least 2 of the following: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine physical activity 2
• Accompanied by nausea/vomiting and/or photophobia/phonophobia 2
• Note that approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) that can mimic sinusitis—consider migraine first rather than "sinus headache" 4, 1

Tension-Type Headache

• Accounts for approximately 30% of pediatric headaches 1
• Bilateral, pressing/tightening quality, mild-to-moderate intensity, not aggravated by routine physical activity 2
• Absence of photophobia/phonophobia and nausea/vomiting correlates with tension-type headache 6

Acute Treatment

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

• Acetaminophen 15 mg/kg every 4-6 hours (maximum 650 mg per dose) is an alternative 1, 2
• For adolescents (12-17 years), triptans (sumatriptan, zolmitriptan, rizatriptan, almotriptan) or combination sumatriptan/naproxen may be considered 2
• Bed rest alone may be sufficient for brief attacks in younger children 1

Preventive Therapy

Consider preventive treatment when headaches interfere with the child on ≥2 days per month despite optimized acute treatment, or when there is frequent or disabling headache. 1, 2

• Amitriptyline combined with cognitive-behavioral therapy, topiramate, or propranolol may be effective 2, 1
• Note that pediatric-specific efficacy data are lacking for these medications 1
• Educate patients and families on lifestyle factors, migraine triggers, and avoiding overuse of acute medication 2

Follow-Up and Referral

• Use headache calendars to evaluate treatment effectiveness and adverse events 2
• When results are suboptimal, review the diagnosis, treatment strategy, dosage, and adherence 2
• Refer to pediatric neurology or headache specialist if acute medication provides insufficient relief, if preventive therapy is being contemplated, or if diagnostic uncertainty remains 1, 2

Common Pitfalls to Avoid

• Do not skip fundoscopic examination—it is essential for detecting increased intracranial pressure 1
• Do not order routine neuroimaging without red flags, as the yield is <1% in children with normal examination 4, 1
• Do not diagnose "sinus headache" without considering migraine first, as cranial autonomic symptoms are common in pediatric migraineurs and frequently lead to misdiagnosis 4, 1
• Do not delay imaging with MRI in acute emergency settings when hemorrhage is suspected—CT is the appropriate rapid initial modality 1
• Remember that 94% of children with brain tumors have abnormal neurological findings at diagnosis, and 60% have papilledema 4, 1