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Pediatric Headache: Five Things You Need to Know About Diagnosis and Management

Pediatric Headache: Five Things You Need to Know About Diagnosis and Management

Headache is common in children. Studies have shown that almost 60% of kids complain of a headache at some point during childhood and that 8% of children and teens have migraines.1

Here are 5 important things you need to know about diagnosis and management of pediatric headache, and a bonus point.

1. When should I be concerned about the child with a headache, and when does concern warrant imaging?

Approximately two-thirds of your patients get headaches, but most won’t seek treatment for the pain. Those who do seek help do so for unusually intense headaches or headaches that last longer than usual. Longer duration and greater intensity, however, don’t necessarily translate as more dangerous. Here are the key signs and symptoms that mean trouble:

A rapidly progressing headache. In pediatrics, head pain that rapidly progresses typically is a manifestation of infection. The infection may be a simple viral illness to a potentially lethal illness, such as meningitis. Let the clinical presentation guide your evaluation.

A headache that slowly worsens over a month or longer. In this setting, consider and rule out a space-occupying lesion. MRI is the study of choice because it offers a better view than does a CT scan of the posterior fossa, where pediatric brain tumors often develop.

A change in the nature of the headache. Meningitis or brain tumors can develop even in migraineurs, so when your patient says “This headache is different from all the rest,” listen.

Alarming associated signs or symptoms. Any alarming neurologic sign or symptom (eg, parasthesias) or generalized sign or symptom (eg, vomiting or fever) should raise your level of concern for secondary cause. For example, while hemiplegic migraine does exist, you need to rule out intracranial pathology first. A fundoscopic exam is mandatory in such patients.

A family history of headache. While not a cardinal sign, the great majority of patients with a primary headache, (migraine or tension-type headache [TTH]) have a family history of headache. If the answer to the question “Does anyone else in the family have headaches?” is “no,” it should raise your index of suspicion.

2. Is it a sinus infection?

Many patients who consult a headache specialist have been told numerous times in the past that they have sinus infections and they have been treated with one or more courses of antibiotics. Since the pain of both sinus and migraine headaches is transmitted via the trigeminal nerve, the presentations can be similar. It is helpful to refer to the 2001 American Academy of Pediatrics clinical practice guidelines on sinusitis which state:

“The diagnosis of acute bacterial sinusitis is based on. . . upper respiratory symptoms that are either persistent or severe.”2
    The persistent symptoms of significance are nasal or post-nasal discharge, daytime
or both lasting at least 10 to 14 days, and the severe symptoms included a fever
    of at least 39° C (102° F) with purulent nasal discharge for at least 3 days in an ill
    appearing child
. Note that “headache” is not included.2

The paper notes that unilateral frontal or periorbital head pain may be present, but is not a necessary part of the diagnosis.

Bottom line: Headache without purulent nasal discharge is not sinusitis.

3. Is it a migraine?

TTH and migraine are the 2 primary headaches seen in pediatrics. In general, both are intermittent headaches separated by pain-free intervals. Migraine pain is usually more severe than pain from TTH, although this may be difficult to determine in a child. Pediatric migraines also can be bilateral and may not be characterized as throbbing—cardinal features many of us learned incorrectly were necessary diagnostic criteria. The key determining factor is the presence or absence of autonomic symptoms. If the headache is accompanied by nausea/vomiting, photophobia, phonophobia, or dizziness, it is a migraine. If not, it is a TTH.

4. When the diagnosis is migraine, when and how do I use a triptan? How do I choose the right one?
Please note that, although triptans are used universally by pediatric headache specialists, only almotriptan (Axert) is FDA- approved for use in children—and only for those aged 12 years and older.

Some migraine patients respond well to non-steroidal antiinflammatory drugs (NSAIDs), however, many do not.  As a result, triptans have become the mainstay of anti-migraine therapy in children and teens as they are in adults.  Sumatriptan (Imitrex) is best known but others are available (Table).

The most important thing to teach a migraine patient and her/his parents is to take the triptan IMMEDIATELY at the onset of headache. I use a football analogy with many of my patients. It is much easier to tackle the running back in the backfield, before he gets going, than it is to chase him down when he has broken through and is running with a full head of steam.

The triptan can be re-dosed in 2 hours if necessary, but triptans should not be used to treat more than 3 headaches in a week because of the increased risk of triggering medication-induced headache.

Figure 1
(Click image to enlarge)

5. Are selective-serotonin or selective-serotonin-norepinephrine reuptake inhibitors safe for patients who take triptans for migraines?

There has long been concern that a SSRI or SNRI given to a patient taking triptans would increase the risk of serotonin syndrome. In 2010, the American Headache Society published its position paper on this question, stating: “The current available evidence does not support limiting the use of triptans with SSRIs or SNRIs…due to concerns for serotonin syndrome. However…caution is certainly warranted.”3

So: these SSRI/SNRI and triptan medications can be used together but one needs to be aware of the concerns and consider the risk/benefit ratio.

6. Bonus question. When do I call in the reinforcements (ie, consult/referral)?

Patients who experience frequent or chronic migraine (>15 headaches/ month) will most likely need prophylaxis. In such cases, it is a good idea to consult with a colleague experienced in pediatric headache care, whether it is a pediatric neurologist or a pediatric headache specialist.
That said, it is always appropriate to refer a patient if or when you are uncomfortable with the diagnosis or treatment.


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