Pediatric headache accounts for 1% of emergency department visits. The vast majority of headaches in children have a benign etiology. Factors associated with serious or dangerous causes of headache include preschool age, occipital location, recent onset of headache, and inability of the child to describe the quality of the head pain.
Headaches can be classified as primary or secondary. Primary headaches are associated with normal physical exam findings, are self-limited, and may be recurrent. Examples of primary headache include physiologic or functional (migraine, tension, cluster). Secondary headaches are usually anatomic (vascular malformation, tumor) or infectious (sinusitis, dental abscess), and have higher morbidity and mortality if left untreated. A careful history and physical examination should focus on identifying or excluding secondary headaches. Historical findings that suggest secondary headache include acute onset; associated fever or stiff neck; morning vomiting; behavioral changes; altered mental status; “worst ever” headache; sleep disturbance; associated trauma or toxic exposure; or aggravation by coughing, Valsalva, or lying down. Physical findings suggestive of secondary headaches include blood pressure abnormalities, nuchal rigidity, head tilt, ptosis, retinal hemorrhage or papilledema, visual field defects, and neurologic findings (altered mental status, ataxia, and hemiparesis).
Diagnosis and Differential
Pertinent historical features of pediatric headache include severity and quality of pain, age of first occurrence, precipitants, rapidity of onset, location, duration, and associated symptoms. Physical examination should include a thorough general examination with careful attention to the neurologic examination, including cranial nerves, gait, strength, and mental status. The history and physical exam should guide the work up. For instance, CT is indicated to rule out suspected intracranial hemorrhage. Magnetic resonance imaging better visualizes the posterior fossa, the most common location of pediatric brain tumors, and either modality may be used for space-occupying lesions elsewhere. Importantly, neuroimaging in children is usually not indicated unless there is an abnormal neurologic exam, altered mental status, concurrent seizures, a recent “worst headache of life” complaint, or change in type of headache.
Emergency Department Care and Disposition
For secondary headaches, evaluate and treat underlying cause and pain.
For primary headaches, narcotics are not recommended. Most primary headaches respond to ibuprofen 10 mg/kg or acetaminophen 15 mg/kg.
For migraines: prochlorperazine 0.15 mg/kg, metoclopramide 0.1 mg/kg, or ketorolac 0.5 mg/kg are widely used for abortive migraine therapy. Metoclopramide and prochlorperazine are often given with diphenhydramine 1 mg/kg to prevent extrapyramidal side effects. “Migraine cocktails” that include ketorolac, prochlorperazine or metoclopramide, and diphenhydramine appear effective and safe. Sumatriptan 5 to 10 mg (in children weighing 20 to 39 kg) or 20 mg (> 40 kg children) nasal spray or 0.1 mg/kg subcutaneously is commonly used.
Cluster and tension headaches are managed much the same way as migraines. Sumatriptan as dosed above and high-flow oxygen(7 L/min non-rebreather mask) can be used for cluster headaches. Tension headaches usually respond to first-line oral therapy such as ibuprofen 10 mg/kg.
For headaches that disrupt activities of daily living ...