Headache (peds)
Background
Clinical Features
Differential Diagnosis
Pediatric Headache
- Primary headache
- Secondary headache
Evaluation
Work-up
- Neuroimaging
- Routine imaging is not indicated in children with recurrent HA headaches and normal neuro exam
- Consider imaging if abnormal neuro exam, altered mental status, concurrent seizure, severe HA or change in type
Diagnosis
- Predictors of a surgical space-occupying lesion
- Headache of <6 months' duration
- Sleep-related headache
- Vomiting
- Confusion
- Absence of visual symptoms
- Absence of family history of migraine
- Abnormal findings on neuro exam
- Torticollis
- Effortless vomiting but no GI complaints suggestive of elevated ICP
- Strongly consider imaging in patients under 5 yrs who present with headaches
Management
| Headache Type | Treatment | Comment |
|---|---|---|
| Migraine | Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | Ibuprofen superior to acetaminophen in one trial |
| Sumatriptan, 10 milligrams via nasal spray (20–39 kg) or 20 milligrams via nasal spray (>40 kg), or 0.06 milligram/kg SC | Nasal or injectable preferred; no difference between oral sumatriptan and placebo | |
| Rizatriptan, 5 milligrams PO | Efficacy not statistically significant over placebo | |
| Dihydroergotamine, 0.1 milligram/kg (ages 6–9), 0.15 milligram/kg (ages 9–12), 0.2 milligram/kg (ages 12–16) | Contraindicated in complex migraine | |
| Prochlorperazine, 0.15 milligram/kg IV | Consider diphenhydramine 1 milligram/kg to prevent or treat dystonic reactions | |
| Cluster | 100% oxygen at 7 L/min via non-rebreather mask at onset of headache | Most useful at onset of symptoms, less effective later in course of headache |
| Ergotamine, 0.1 milligram/dose (ages 6–9), 0.5 milligram/dose (ages 9–12), 0.75 milligram/dose (ages 12–16) | — | |
| Sumatriptan | Nasal spray or IM dosing as for migraine | |
| Lidocaine, 1% solution in ipsilateral nostril | Effective for mild to moderate pain, can instill via atomizer and syringe | |
| Prednisone, 1–2 milligrams/kg for 10 d with subsequent 7-d taper | Effective at terminating prolonged cluster headaches and preventing recurrence | |
| Tension | Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | — |