Headaches in Children: Diagnostic Evaluation Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with headache
Physical Examination Guide
Systematic approach to examining a child with headache
Diagnostic Approach
Initial Assessment
For a child presenting with headache, the initial assessment should include:
- Detailed history of headache characteristics, pattern, and associated symptoms
- Complete neurological examination
- Assessment of developmental and psychosocial factors
- Evaluation of red flags that may indicate serious underlying pathology
Diagnostic Criteria for Primary Headaches
Different diagnostic criteria for common primary headaches in children:
| Headache Type | Definition | Key Features |
|---|---|---|
| Migraine without Aura | ≥5 attacks, lasting 2-72 hours, with at least 2 of: unilateral location, pulsating quality, moderate/severe pain, aggravation by routine activity; and at least 1 of: nausea/vomiting, photophobia and phonophobia | In children: often bilateral, shorter duration (1-72 hours), frontal/temporal, may include dizziness |
| Migraine with Aura | ≥2 attacks with aura symptoms developing over ≥5 minutes, lasting 5-60 minutes, followed by headache | Visual aura most common (scotoma, fortification spectra), sensory/speech disturbances can occur |
| Tension-type Headache | ≥10 episodes, lasting 30 minutes to 7 days, with at least 2 of: bilateral, pressing quality, mild/moderate intensity, not aggravated by routine activity; no nausea/vomiting, may have photophobia OR phonophobia (not both) | Often described as "band-like," pressure; more common in older children and adolescents |
| New Daily Persistent Headache | Daily headache without remission within 3 days of onset, present >3 months, >15 days/month | Patient often recalls exact onset date, characteristics may be mixed migraine/tension features |
Differential Diagnosis
| Category | Conditions | Red Flags |
|---|---|---|
| Intracranial Pressure Disorders |
- Brain tumor - Idiopathic intracranial hypertension - Hydrocephalus - Intracranial hemorrhage - Venous sinus thrombosis |
- Headache worse when lying down or in morning - Progressive worsening of headache - Neurological deficits - Papilledema - Vomiting without nausea |
| Infections |
- Meningitis - Encephalitis - Brain abscess - Sinusitis - Systemic infections |
- Fever - Neck stiffness - Altered mental status - Focal neurological signs - Purulent nasal discharge |
| Vascular Disorders |
- Arteriovenous malformation - Aneurysm - Vasculitis - Dissection - Stroke |
- Thunderclap headache - Focal neurological deficits - Altered consciousness - Family history of vascular disorders - Headache with exertion |
| Trauma |
- Concussion - Post-traumatic headache - Subdural hematoma - Epidural hematoma |
- Recent head injury - Loss of consciousness - Worsening headache after injury - Memory problems - Behavioral changes |
| Other |
- Medication overuse headache - Substance use/exposure - Carbon monoxide poisoning - Hypertension - Ocular disorders |
- Regular pain medication use - Multiple household members affected - Severe hypertension - Visual changes - Exposure to toxins |
Laboratory Studies
Consider these studies when red flags are present:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Complete Blood Count | Assess for infection, inflammation, anemia | Fever, fatigue, systemic symptoms |
| Erythrocyte Sedimentation Rate / C-Reactive Protein | Screen for inflammation | Suspected vasculitis, infection, inflammatory condition |
| Comprehensive Metabolic Panel | Evaluate for metabolic causes | Electrolyte disorders, renal or liver dysfunction |
| Thyroid Function Tests | Assess for thyroid disorders | Symptoms of hypothyroidism/hyperthyroidism |
| Lumbar Puncture | Evaluate CSF pressure and composition | Suspected meningitis, encephalitis, IIH (after neuroimaging) |
Neuroimaging
Reserve for specific clinical scenarios:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| CT Scan | Rapid evaluation for acute emergencies | Acute trauma, thunderclap headache, focal deficits, altered mental status |
| MRI with contrast | Detailed structural evaluation | Abnormal neurological exam, persistent focal headache, seizures, progressive worsening |
| MR Venography | Evaluate venous sinus thrombosis | Suspected venous thrombosis, IIH workup, risk factors for thrombosis |
| MR Angiography | Evaluate vascular abnormalities | Thunderclap headache, family history of aneurysm, suspected vasculitis |
Other Diagnostic Studies
| Study | Clinical Utility | When to Consider |
|---|---|---|
| Electroencephalogram (EEG) | Evaluate for seizure activity | Headache with altered consciousness, suspected epilepsy, migraine variants |
| Polysomnography | Evaluate for sleep disorders | Morning headaches, snoring, witnessed apneas, excessive daytime sleepiness |
| Ophthalmologic Evaluation | Assess visual acuity, visual fields, fundoscopy | Visual symptoms, suspected IIH, screening for papilledema |
| Sinus Imaging | Evaluate for sinusitis | Facial pain, purulent discharge, fever, sinus tenderness |
Diagnostic Algorithm
A stepwise approach to diagnosing headache in children:
- Comprehensive headache history including pattern, triggers, associated symptoms
- Complete physical and neurological examination with attention to vital signs
- Screen for red flags indicating serious underlying pathology
- Apply ICHD-3 criteria to diagnose primary headache disorders
- Identify comorbid conditions (sleep disorders, anxiety, depression)
- Consider neuroimaging if red flags present or atypical features
- Targeted laboratory studies based on clinical suspicion
- Headache diary to document pattern, frequency, and response to interventions
- Specialist referral for complex or concerning cases
Management Strategies
General Approach to Management
Key principles in managing pediatric headache:
- Biopsychosocial approach: Address biological, psychological, and social factors
- Education: Provide information about headache mechanisms and management
- Lifestyle modifications: Target sleep, hydration, exercise, stress management
- Trigger identification: Recognize and minimize headache precipitants
- Stepwise pharmacological approach: Start with simple analgesics before specialized treatments
- Regular follow-up: Monitor response to interventions and adjust as needed
Non-Pharmacological Interventions
| Intervention | Description | Evidence Level |
|---|---|---|
| Lifestyle Modifications |
- Regular sleep schedule - Adequate hydration (1-2L/day) - Regular meals - Regular physical activity - Limited screen time |
Moderate; observational studies show benefit |
| Cognitive Behavioral Therapy |
- Stress management techniques - Relaxation training - Cognitive restructuring - Biofeedback |
High; multiple RCTs support efficacy |
| Trigger Avoidance |
- Food trigger identification - Environmental trigger reduction - Stress management - Headache diary |
Moderate; clinical experience supports, limited controlled studies |
| Physical Therapy |
- Stretching and strengthening exercises - Posture correction - Massage - Heat/cold therapy |
Moderate; beneficial for tension-type headaches |
| School Accommodations |
- 504 plans or IEPs - Modified schedules - Rest periods - Extended time for assignments |
Low to moderate; improves functioning and reduces stress |
Acute Pharmacological Treatment
| Medication | Dosing | Evidence and Considerations |
|---|---|---|
| Acetaminophen |
- 10-15 mg/kg/dose PO/PR q4-6h - Max: 75 mg/kg/day, not to exceed 4g/day |
- First-line for mild to moderate headache - Well-tolerated - Monitor for hepatotoxicity with long-term use - Moderate evidence for efficacy |
| Ibuprofen |
- 10 mg/kg/dose PO q6-8h - Max: 40 mg/kg/day, not to exceed 2.4g/day |
- First-line for mild to moderate headache - More effective than acetaminophen for migraine - Monitor for GI side effects - High evidence for efficacy |
| Triptans |
- Sumatriptan nasal: 5-20mg based on weight - Rizatriptan: 5-10mg based on weight - Almotriptan: 6.25-12.5mg based on weight |
- For moderate to severe migraine - Second-line after NSAIDs - Contraindicated in hemiplegic migraine and basilar migraine - High evidence for efficacy in adolescents |
| Antiemetics |
- Ondansetron: 0.15 mg/kg/dose (max 8mg) - Prochlorperazine: 0.1-0.15 mg/kg/dose |
- Adjunctive therapy for nausea/vomiting - May have independent analgesic effect - Monitor for extrapyramidal symptoms - Moderate evidence for efficacy |
Preventive Pharmacological Treatment
Consider when headaches occur >4 days/month with disability or significant impact on quality of life:
| Medication | Dosing | Evidence and Considerations |
|---|---|---|
| Topiramate |
- Start: 0.5-1 mg/kg/day divided BID - Titrate: Increase by 0.5-1 mg/kg/week - Target: 2-3 mg/kg/day (max 200mg/day) |
- FDA approved for migraine prevention in adolescents - Monitor for cognitive side effects, paresthesias, weight loss - High evidence for efficacy - Teratogenic (important in adolescent females) |
| Propranolol |
- Start: 0.5-1 mg/kg/day divided BID-TID - Titrate: Increase gradually - Target: 2-4 mg/kg/day (max 160mg/day) |
- Long history of use in pediatric migraine - Contraindicated in asthma, diabetes, depression - Monitor for fatigue, dizziness, depression - Moderate evidence for efficacy |
| Amitriptyline |
- Start: 0.25-0.5 mg/kg/day at bedtime - Titrate: Increase by 0.25 mg/kg every 2 weeks - Target: 1-2 mg/kg/day (max 150mg/day) |
- Useful for comorbid insomnia, anxiety - Monitor for sedation, dry mouth, weight gain - Begin at low dose and titrate slowly - Moderate evidence for efficacy |
| Cyproheptadine |
- Age 2-6: 2 mg BID - Age 7-14: 4 mg BID - Age >14: 4 mg TID |
- Often used in younger children - Monitor for sedation, weight gain - Limited evidence but clinical experience supports use - Moderate evidence for efficacy |
| CGRP Monoclonal Antibodies |
- Erenumab, Galcanezumab, Fremanezumab - Dosing based on specific medication |
- Emerging therapy in adolescents - Limited pediatric data, extrapolated from adult studies - Consider for refractory cases - Low to moderate evidence in pediatrics |
Management of Specific Headache Types
| Headache Type | Acute Management | Preventive Approaches |
|---|---|---|
| Migraine |
- Early intervention with NSAIDs/triptans - Rest in dark, quiet environment - Hydration - Consider antiemetics if needed |
- Topiramate or propranolol first-line - Regular sleep schedule - Trigger identification/avoidance - CBT and biofeedback |
| Tension-type Headache |
- NSAIDs/acetaminophen - Relaxation techniques - Massage/heat therapy - Stress reduction |
- Physical therapy - Stress management - Amitriptyline if chronic - Address psychosocial factors |
| New Daily Persistent Headache |
- Often resistant to acute treatments - Multimodal approach - NSAIDs may help temporarily - Address comorbid anxiety/depression |
- Multimodal approach essential - Combination pharmacotherapy - Intensive CBT - Physical therapy - Consider inpatient treatment for severe cases |
| Post-traumatic Headache |
- NSAIDs - Cognitive rest initially - Gradual return to activities - Avoid triggers |
- Graduated return to school/activities - Exercise as tolerated - Consider amitriptyline or topiramate - Vestibular therapy if concurrent dizziness |
Special Populations and Considerations
| Population | Considerations | Approach |
|---|---|---|
| Young Children (<6 years) |
- Often unable to clearly describe symptoms - May present with behavioral changes - Higher index of suspicion for secondary causes |
- Lower threshold for neuroimaging - Caregiver-reported observation important - Consider cyproheptadine for prevention - Simplified behavioral interventions |
| Adolescents |
- Hormonal influences (menstrual migraine) - Academic pressures - Sleep disturbances - Screen use/lifestyle factors |
- Address sleep hygiene - School accommodations when needed - Consider hormonal management for menstrual migraine - Involve in management decisions |
| Children with Developmental/Neurological Disorders |
- May have atypical presentation - Communication barriers - Higher risk for secondary headache - Medication interactions |
- Lower threshold for diagnostic evaluation - Consider behavioral manifestations of pain - Careful medication selection - Coordinate with other specialists |
| Children with Psychiatric Comorbidities |
- Bidirectional relationship with headache - Treatment resistance more common - Risk for medication overuse |
- Integrated approach with mental health - Consider medications that address both conditions - CBT and mindfulness essential - Family-based interventions |
When to Refer
- Neurology referral: Abnormal neurological examination, red flag symptoms, refractory headaches
- Pain clinic: Severe disability, medication overuse, complex pain syndromes
- Mental health: Significant anxiety/depression, psychosocial factors, functional disability
- Physical therapy: Cervicogenic component, postural issues, post-traumatic headache
- Ophthalmology: Visual symptoms, suspected papilledema, vision changes
- Neurosurgery: Evidence of increased intracranial pressure, structural abnormalities
Patient and Family Education
- Headache education: Pathophysiology, triggers, management strategies
- Lifestyle counseling: Sleep hygiene, hydration, nutrition, exercise, stress management
- Medication education: Proper use, potential side effects, avoiding medication overuse
- School advocacy: Help families obtain appropriate accommodations when needed
- Long-term outlook: Natural history, prognosis, self-management strategies
