Headache in Children: Advice for Referrers

RHC for Health Professionals
NHS GGC

Headache is common in children, increasing in incidence from early childhood to adolescence. Primary headaches, due to no specific underlying cause, are the most common cause of chronic headaches in children. 50% of primary headaches in children are due to viral illnesses, migraines, or tension type headache. Secondary headaches, i.e. due to an underlying pathology, need to be considered in all children presenting with headache but are much less common.

Red Flags

Consider red flags – refer urgently or consider acute assessment if:  

  • Acute and severe headache
  • Focal neurological symptoms
  • Nocturnal headache that wakes child, nocturnal vomiting, or early morning headache/vomiting
  • Deterioration in school performance

Red flag features on Examination: 

  • Increasing head circumference
  • Abnormal head position
  • New focal neurological abnormalities
  • Signs of raised intracranial pressure (papilloedema, altered mental state, ataxia)
  • Signs of meningism

Further information on red flags available from www.headsmart.org.uk

Who to Refer

When to refer:

  • Concern around possible secondary headache/red flag features
  • Diagnosis unclear
  • Ongoing management and treatment advice

Consider on-the-day discussion for potential acute assessment if:

  • Red flag features (see above) in those under 12 years
  • Any headache in those under 4 years

Information to Include - History

Please include the following points from history in the referral letter

  • Description of headache - Location, Quality, Intensity, Duration, Frequency
  • Effect on Activities
  • Analgesia - type and how often
  • Common triggers 
  • Any aura or warning
  • Photo/phonophobia, nausea, vomiting

General History: 

  • Psychosocial history
  • Lifestyle – including sleep, eating, drinking (including intake of caffeine-containing drinks), screen time, exercise
  • Family History including headache

Please include the following points from the clinical examination in the referral letter

  • Growth parameters - Weight/Height/BMI/OFC
  • Heart rate and blood pressure
  • Scalp and Face – is there any local pathology, e.g. swelling, cellulitis
  • Neurological Examination
  • Fundoscopy if available

Information to Include - Examination

Please include the following points from the clinical examination in the referral letter

  • Growth parameters - Weight/Height/BMI/OFC
  • Heart rate and blood pressure
  • Scalp and Face – is there any local pathology, e.g. swelling, cellulitis
  • Neurological Examination
  • Fundoscopy if available

Suggestions for Management whilst waiting for Outpatient Appointment

  • Optician review
  • Ask child/young person or parent to keep a headache diary
  • Lifestyle advice including rest, and activity
  • Ensure adequate fluid (water or diluting juice) intake Approximate volumes per 24 hours by age and sex are:
    • Age 1-2 years: 900mls
    • Age 2-3 years: 1 litre
    • Age 4-8 years: 1.2 litres per day
    • Age 9-13 years:
      • Boys: 1.6 litres
      • Girls: 1.5 litres
    • Age over 13 years:
      • Boys: 2 litres
      • Girls: 1.6 litres
  • Avoidance of medication overuse - don’t use more than 2 days per week for any headache
  • Avoidance of triggers only if clearly associated
  • Consider trial of triptan, antiemetic and/or migraine prophylaxis in cases of migraine

Useful resources for Parents

Useful Resources for Health Professionals

Websites:

Articles:

  • Ryan S.  Medicines for migraine.  Archives of Disease in Childhood - Education and Practice 2007;92:ep50-ep55
  • Jayawant S, Barnes NP.  Migraine.  Archives of Disease in Childhood - Education and Practice 2005;90:ep53-ep57

Editorial Information

Last reviewed: 25/11/2024

Next review date: 30/11/2029

Author(s): Dr I Morgan, Consultant Medical Paediatrics, Dr L Nairn, Consultant Medical Paediatrics.

Approved By: Medical Paediatrics