Authors: Tessa Davis, Henry Goldstein, Ben Lawton & Andrew Tagg / Codes: PAP12 / Published: 12/09/2018
Headaches are one of the most common presentations to ED and may be primary or secondary. Migraine is the most common type of primary headache, but the majority of headaches are benign in nature and require no investigations. This is an approach to the child presenting to ED with headaches. We want to help you differentiate between those benign ones that just require simple analgesia and reassurance and those that require further investigation.
Getting a good history about the nature and type of the headache is crucial. This will include working out what the course of the headaches are i.e. how frequent they are, when they started, any recent change in frequency. Then ask for a description of the actual headache i.e. was there an aura beforehand, where is the pain, how long does it last, what are the associated symptoms (nausea, vomiting, dizziness, visual disturbance, abdominal pain), what are the aggravating and relieving factors? It’s important to ask about any neurological signs during the attack e.g. weakness, numbness, loss of sensation. Also ask specifically about medications taken and any family history of headache or migraine.
The examination should focus on looking for causes of headache. Most of the time there will be nothing to find. It should include include an overall growth and developmental assessment, coupled with a head circumference measurement in a younger child. Look for potential secondary causes such as signs of sinusitis, dental problems, otitis media, TMJ dysfunction. Whilst fundoscopy in a young child is pretty much impossible without special equipment you must check their blood pressure. The core part of the examination will be neurological cranial nerves, limb examination, gait, and cerebellar examination.
Know the red flags
We all worry about missing the child with a brain tumour, and it’s important to know the red flags.
HeadSmart has a wonderful website aiming to provide early recognition of brain tumours and provides advice on concerning features.
You should have a higher index of suspicion if the headache is worse in the early morning, especially when it is associated with vomiting or made worse by coughing or straining (this suggests raised intracranial pressure). Any focal neurological signs during or after the headache should prompt consideration for further investigation too, as should an abnormal neurological exam. If the headache is associated with confusion or reduced consciousness it is much less likely to be a benign primary headache. Occipital headaches are also uncommon in children so should prompt suspicion as should persistent headaches in children under 4 years of age.
There are two major types of migraine migraine without aura and migraine with aura.
Migraine without aura is a headache with associated symptoms lasting 4-72 hours. Migraines are often associated with photophobia, the pain is commonly fronto-temporal and can be unilateral. It can feel like a throbbing/pulsing pain and children can experience nausea. There is an ICHD-3 classification which gives diagnostic criteria for migraines:
When taking the history from a child with migraines, make sure to ask about the family history and also to see if the child/family can identify any triggers e.g. chocolate, MSG, citrus, menstruation.
These are usually described as a band-like pain that is persistent but not progressive. Tension headaches may be more common in children undergoing stressful life events, such as parental separation or exams – consider this when you are assessing the child. Use the HEADSSS screen in older kids to look for a cause.
Most tension headaches are managed by reassurance, reducing any stressors, and simple analgesia (paracetamol and ibuprofen).
These are less common but can occur in children. They present as (strictly) unilateral pain in or around the eye or the temporal region. They can last for up to three hours, and can occur as frequently as eight times per day. Often there are associated unilateral facial signs – conjunctival injection, rhinorrhoea, lacrimation, or facial sweating.
Occasionally the child can be treated with triptans for prophylaxis, otherwise they can try simple analgesia (paracetamol and ibuprofen).
These are also uncommon in children and occur when children take regular, daily medication (e.g. paracetamol) for their headache. The headache should resolve within a few weeks of stopping the medication.
Raised intracranial pressure
We discussed above signs of raised intracranial pressure (morning symptoms).
Always make sure to ask if there has been any recent trauma it’s possible that the family hadn’t connected the two and therefore forgot to mention it previously. This could be signs of an intracranial bleed or could be part of a concussion.
This child is often unwell with irritability, photophobia, and neck stiffness though the classical Brudzinskis and Kernig’s signs that we all learned about in medical school are very non-specific. Children may have meningitis without these classic signs so be conscious of considering this diagnose in children with irritability and particularly reduced consciousness.
In most children, simple analgesia with paracetamol and ibuprofen are well-tolerated and effective treatments for headaches, especially for migraines. Anti-emetics may be considered if the child gets lots of nausea and vomiting with a migraine (ondansetron or prochlorperazine in older children).
Triptans can be used for treatment of migraine too (can have nasal sumatriptan) as a stat does in ED in children over 12 years of age.
(More serious causes and those with red flag symptoms will need investigation and treatment accordingly).
Consider the social side
The impact of the headaches on the child’s daily life is important, and we know that stress can contribute to headaches too. You should ask about family stressors, school progress, and friends.
Identifying stress or conflict can help reduce headaches, and also trying to pinpoint what the headache triggers are can allow avoidance strategies to be put in place (e.g. avoidance of caffeine, chocolate, extreme tiredness, missing meals). If they get recurrent headaches it is worth asking the parents to keep a headache diary, listing intensity and nature of the headaches as well as the daily diet. This may help you or the specialist make links otherwise not appreciable.
Whilst headaches can be distressing for both the patient and the parent alike they are very rarely serious. In the emergency department our role is to rule out any serious causes, provide reassurance and only investigate when clinically appropriate.
If you go through your PEM rotation without regularly visiting the dontforgetthebubbles website, you are missing a trick. This is an excellent resource for acute paediatrics, and has a bubble wrap section with regular blogs on emerging research. The team also hold an annual conference on a range of acute paediatric topics which is highly recommended. It is usually held in Australia, but the good news is that it will be in the UK for the first time on 17th-19th June in London.
- The international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
- International Headache Society, Headache, Clinical Practice Guidelines. Royal Childrens Hospital, Melbourne. Accessed online on 14thMay 2018
- HeadSmart: early diagnosis of brain tumours. Accessed online 15th June 2018