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This document provides clear information about the assessment, investigation and management of children that present with headaches.
Children presenting to secondary care with headaches.
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.
What was your child doing when the headache started?
How long has your child had a headache/ headaches for?
What does your child do when they have a headache?
What makes the headache worse?
Has your child’s behaviour changed?
Has your child had a recent head injury?
Has your child had any other symptoms?
Did your child feel anything before the headache came on?
What painkillers has your child had today? What painkillers do they have every day?
How many drinks does your child normally have in a day?
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?
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:
Growth Chart: Height, weight and head circumference should be charted.
Full Neurological Examination including:
You should now be able to categorise the patient’s headache into one of four types:
|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|
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.
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:
LP - again the timing in relation to possible CT should be discussed with a senior colleague, but must be considered if suspecting meningitis.
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.
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
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:
D. During headache at least one of the following
E. No evidence of organic disease
A. At least two attacks fulfilling B
B. At least three of the following characteristics:
C. No evidence of organic disease.
Last reviewed: 18 August 2017
Next review: 31 May 2020
Author(s): Fiona Russell
Approved By: Paediatric Clinical Effectiveness & Risk Committee