Headache (peds)

Background

Headache with effortless vomiting but no GI complaints is characteristic of elevated intracranial pressure

Practice guidelines state that routine imaging is not indicated in children with recurrent headaches and normal findings on neurologic examination. Imaging should be considered in children with abnormal findings on neurologic examination or altered mental status, concurrent seizures, or both, as well as in children whose medical history indicates the recent onset of severe (worst) headache, a change in the type of headache, or associated features that suggest neurologic dysfunction

Etiology

• Primary Headache
  • Migraine
  • Tension
  • Cluster
• Secondary Headache
  • Viral illness and fever
  • Post-traumatic
  • VP shunt malfunction
  • CO poisoning
  • Epidural/subdural hematoma
  • Brain abscess
  • Pseudotumor cerebri
  • Meningitis
  • Space-occupying lesion
  • AVM
  • Sinusitis
  • Dental abscess
  • Otitis

Diagnosis

• Predictors of a surgical space-occupying lesion
  • Headache of <6 months' duration
  • Sleep-related headache
  • Vomiting
  • Confusion
  • Absence of visual symptoms
  • Absence of family history of migraine
  • Abnormal findings on neuro exam

Abrupt occurrence of severe headache due to a serious underlying condition, such as a brain tumor or intracranial hemorrhage, is typically associated with one or more objective findings on neurologic examination

Treatment

Headache Type	Treatment	Comment
Migraine	Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR	Ibuprofen superior to acetaminophen in one trial
	Sumatriptan, 10 milligrams via nasal spray (20–39 kg) or 20 milligrams via nasal spray (>40 kg), or 0.06 milligram/kg SC	Nasal or injectable preferred; no difference between oral sumatriptan and placebo
	Rizatriptan, 5 milligrams PO	Efficacy not statistically significant over placebo
	Dihydroergotamine, 0.1 milligram/kg (ages 6–9), 0.15 milligram/kg (ages 9–12), 0.2 milligram/kg (ages 12–16)	Contraindicated in complex migraine
	Prochlorperazine, 0.15 milligram/kg IV	Consider diphenhydramine 1 milligram/kg to prevent or treat dystonic reactions
Cluster	100% oxygen at 7 L/min via non-rebreather mask at onset of headache	Most useful at onset of symptoms, less effective later in course of headache
	Ergotamine, 0.1 milligram/dose (ages 6–9), 0.5 milligram/dose (ages 9–12), 0.75 milligram/dose (ages 12–16)	—
	Sumatriptan	Nasal spray or IM dosing as for migraine
	Lidocaine, 1% solution in ipsilateral nostril	Effective for mild to moderate pain, can instill via atomizer and syringe
	Prednisone, 1–2 milligrams/kg for 10 d with subsequent 7-d taper	Effective at terminating prolonged cluster headaches and preventing recurrence
Tension	Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR	—

Source

Tintinalli