Headache (peds)

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Background

Headache Red Flags

Features

  • Sudden onset or accelerating pattern
  • No similar headache in past
  • Age >50 yr or <5 yr
  • Occipitonuchal HA
  • Visual disturbances
  • Exertional or postcoital
  • Family history of SAH or cerebral aneurysm
  • Focal neurologic signs
  • Diastolic BP >120
  • Papilledema
  • Jaw claudication

Clinical Context

Headache in setting of:

Clinical Features

  • Headache

Differential Diagnosis

Pediatric Headache

Evaluation

Work-up

  • Neuroimaging
    • Routine imaging is not indicated in children with recurrent HA headaches and normal neuro exam
    • Consider imaging if abnormal neuro exam, altered mental status, concurrent seizure, severe HA or change in type

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
    • Torticollis
  • Effortless vomiting but no GI complaints suggestive of elevated ICP
  • Strongly consider imaging in patients under 5 yrs who present with headaches


Management

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

Disposition

See Also

External Links

References