Headaches in children

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Objectives

This document provides clear information about the assessment, investigation and management of children that present with headaches. 

Scope

Children presenting to secondary care with headaches. 

Audience

Clinicians involved in the assessment and management of children with headaches.

Children commonly present to the Emergency Department with headache. You must try to evaluate if there is a significant underlying pathology. Therefore you must take a careful history and perform a thorough examination.

History

Questions you should ask in addition to your usual history:

What was your child doing when the headache started?

  • Interrupted sleep – suggests SOL
  • Headache present on wakening – suggests raised ICP

How long has your child had a headache/ headaches for?

  • First or worst
  • Short history
  • Changed or accelerated course
  • In teenagers headache that never goes away suggests SOL

What does your child do when they have a headache?

  • If prohibits normal activities – severe headache
  • If inhibits normal activities – moderate headache
  • Agitated and pacing the floor – suggests cluster headache

What makes the headache worse?

  • Worse on lying down – suggests raised ICP

Has your child’s behaviour changed?

  • Altered personality – suggests SOL

Has your child had a recent head injury?

Has your child had any other symptoms?

  • Vomiting – particularly early morning
  • Fever
  • Photophobia – need to consider meningitis
  • Neck pain or stiffness – suggests meningeal irritation
  • Seizures

Did your child feel anything before the headache came on?

  • Aura are usually visual disturbances

What painkillers has your child had today? What painkillers do they have every day?

  • Chronic use of analgesia may cause Medicine Overuse Headache

How many drinks does your child normally have in a day?

  • Many children have chronic headaches secondary to dehydration

Do they have a lot of caffeine (coke, irn bru) or foods with monosodium glutamate (flavoured crisps, pot noodles)?

Is there any family history of migraine?

Examination

A thorough examination should be performed:

Vital signs: pulse, temperature and BP should be documented in all patients

Assess the level of consciousness and record the GCS

General Physical examination including:

  • Skin – look for rashes or cutaneous lesions eg café-au-lait spots
  • Ears and throat – URTI with fever is a common cause of headache
  • Teeth – check for dental caries/abscess
  • Sinus tenderness – palpate the frontal and maxillary sinuses
  • Head – check for any sign of trauma
  • Neck
    • look for neck stiffness
    • cervical lymphadenopathy

Growth Chart: Height, weight and head circumference should be charted.

Full Neurological Examination including:

  • Fundoscopy – looking for papilloedema or haemorrhage
  • New onset squint or III, IV or VI nerve palsies
  • Focal neurological abnormalities are often present in SOLs
  • Ataxia – look at the patient’s gait
Differential diagnosis

You should now be able to categorise the patient’s headache into one of four types:

Type Description
Isolated Acute Recent onset headache with no prior history of similar episodes (see Appendix 1) e.g. URTI, meningitis, acute intracranial bleed
Acute Recurrent Attacks separated by symptom free intervals e.g. migraine or tension type headache
Chronic Progressive Frequency and severity gradually increases with time and usually indicates increasing ICP e.g. tumour, hydrocephalus
Chronic Non-progressive More frequent and persistent than acute recurrent may occur daily

 

Investigation

Investigations will largely be determined by the differential diagnosis. In general patients with Isolated Acute headache or those with Chronic Progressive headache will require urgent investigation and management in the Emergency Department.

There is no place for “routine bloods”. Blood tests should be appropriate to the differential diagnosis eg FBC, CRP if considering sepsis.

CT Scan

Requests for CT scan are consultant to consultant. Therefore if you think the patient requires an urgent CT you should discuss the need for, and the timing of a CT with a senior colleague.

Indications for CT scanning patients with headache include:

  • Altered GCS
  • Features of increased ICP – papilloedema, night or early morning vomiting
  • New focal neurological deficits
  • Seizures – especially focal
  • Cerebellar dysfunction – ataxia, nystagmus etc
  • Personality change
  • Chronic progressive headache
  • Significant head trauma

LP - again the timing in relation to possible CT should be discussed with a senior colleague, but must be considered if suspecting meningitis.

Management

1) Acute Headache or Chronic Progressive Headache:

If there is a specific diagnosis such as meningitis, SAH, systemic or local infection then treat appropriately. 
All patients need to have adequate analgesia given as early as possible. 
Treat nausea and vomiting eg.ondasetron

If the headache has not significantly resolved, no matter what the probable diagnosis the patient will require a period of observation.

2) Acute Recurrent or Chronic Non-progressive Headache:

These patients should be referred by dictated letter to the Headache Clinic run in the Neurology Department. The patient may be sent out a Headache Diary to complete prior to their attendance.

If Medicine Overuse headache or diet or dehydration is thought to be a contributing factor, alteration in family behaviours prior to their clinic attendance should be discussed.

It is not routine practice to start any other drug therapies for Migraine until they have been assessed at the Headache Clinic.

For further background information: Evaluation of Headaches in Children, Mukhopadhyay S et al (2008): Symposium: Neurology Paediatrics and Child Health 18:1

Appendix 1: Important causes of acute headache
  • Tension headache
    • Infection
    • Local
      • Eyes
      • Ears
      • Teeth
      • Sinuses
      • Skin
      • Lymph node
    • Systemic
      • Viraemia
      • Bacteraemia
      • Meningitis
      • Encephalitis
      • Septicaemia
  • Arterial Hypertension
  • Inflammatory Disease
    • Local
      • Cervical
      • Musculoskeletal
    • Systemic
      • Kawasaki Disease
      • Lupus
      • Other collagen vascular disorders
  • Intracranial
    • Hydrocephalus
    • Intracranial Haemorrhage
    • Brain Tumour
    • Vascular Anomaly
    • Idiopathic Intracranial Hypertension
    • Post Traumatic
  •  Migraine

1) International Headache Society Criteria for Diagnosis of Migraine without Aura

A. At least 5 attacks fulfilling B-D

B. Headache lasting 72 hours (untreated or unsuccessfully treated)

C. Headache has at least 2 of the following characteristics:

  • Unilateral location
  • Pulsating quality
  • Moderate or severe intensity
  • Aggravation by walking stairs or similar physical activity 

D. During headache at least one of the following

  • Nausea and/or vomiting
  • Photophobia or phonophobia 

E. No evidence of organic disease

2) International Headache Society Criteria for Diagnosis of Migraine with Aura

A. At least two attacks fulfilling B

B. At least three of the following characteristics:

  • One or more fully reversible aura symptoms.
  • At least one aura symptom develops gradually over more than 4 minutes or two or more symptoms occur in succession.
  • No aura symptom lasts more than 60 minutes.
  • Headache follows aura with a free interval of more than 60 minutes (it may also begin before or simultaneously with the aura.

C. No evidence of organic disease.

Editorial Information

Last reviewed: 18 August 2017

Next review: 31 May 2020

Author(s): Fiona Russell

Approved By: Paediatric Clinical Effectiveness & Risk Committee