Peds

Headache in Children

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Headache in Children, Headaches in Children, Cephalgia in Children, Pediatric Headache

  • See Also
  1. Headache
  • Epidemiology
  1. Incidence of Headache
    1. Headaches are uncommon in age <3 years (consider secondary causes)
    2. Age 7 years or older: 33% (frequent in 2.5%)
    3. Age 15 years or older: 50% (frequent in 15%)
  2. Gender predominance
    1. Before Puberty: Boys
    2. After Puberty: Girls
  3. Headaches in teens presenting to Emergency Department (all serious causes had neurologic findings)
    1. Upper respiratory tract infection with fever: 55%
    2. Primary Headache syndrome (Migraine or Tension Headache): 18%
    3. Viral Meningitis: 7%
    4. Brain Tumor: 2.5%
    5. Post-ictal Headache following Seizure: 2%
    6. Postconcussive: 2%
    7. Ventricular shunt malfunction: 2%
    8. Undetermined cause: 7%
    9. Lewis (2000) Headache 40:200-3 [PubMed]
  1. Common primary Headaches in Children
    1. Migraine Headache
      1. See Migraine Headache Triggers
      2. See Tyramine-Vasoactive Amines
    2. Tension Headache
  2. Uncommon primary Headaches in Children
    1. Young Children
      1. Hemiplegic Migraine Headache
      2. Ophthalmoplegic Migraine
    2. Older Child, Adolescent and Young adult
      1. Temporomandibular Joint Disorder
      2. Basilar Migraine Headache (female adolescents)
      3. Paroxysmal Hemicrania
        1. Similar to Cluster Headache without Lacrimation
      4. Cluster Headache
        1. Rare in children under age 10 years
      5. Occipital Neuralgia
        1. Rare in younger children (consider Increased Intracranial Pressure in that age group)
  1. See Headache Red Flag
  2. Head and neck infections
    1. Upper Respiratory Infection
    2. Acute Sinusitis
    3. Pharyngitis
    4. Dental Infections
  3. Intracranial Infections
    1. Meningitis
    2. Encephalitis
    3. Intracranial Abscess
      1. Cyanotic heart disease
      2. Immunocompromised
      3. Untreated Sinusitis (e.g. Periorbital Cellulitis)
  4. Intracranial Cause
    1. Hydrocephalus
    2. Cavernous Sinus Thrombosis
    3. Idiopathic Intracranial Hypertension (IIH)
    4. Intracranial Tumor
      1. See Intracranial Mass in Children
      2. See red flags below
      3. Rare cause of Headache in Children (3 in 100,000)
    5. Nontraumatic Intracranial Hemorrhage
      1. See Subarachnoid Hemorrhage
      2. Presentations
        1. Headache with Vomiting
        2. Seizures
        3. Hemiparesis
        4. Glasgow Coma Scale <15
      3. Types
        1. Arteriovenous Malformations
        2. Intracranial Aneurysms
        3. Hematologic disorder (Thrombocytopenia, Hemophilia, Sickle Cell Anemia)
  5. Miscellaneous Causes
    1. See Medication Causes of Headache
    2. Temperomandibular joint dysfunction
    3. Carbon Monoxide Poisoning
    4. Lead Poisoning
    5. Hypertension
      1. See Hypertension Causes in Children
      2. See Hypertensive Crisis
      3. Hypertensive Encephalopathy
        1. Presents with Headache and diastolic Blood Pressure >95th percentile
        2. May be accompanied by Seizures or Vision change
        3. Causes
          1. Renal disease (most common)
          2. Aortic Coarctation
          3. Hyperthyroidism
          4. Pheochromocytoma
          5. Neuroblastoma
          6. Wilms Tumor
  1. See Headache Red Flag
  2. Red Flag Findings typically indicate imaging (MRI or CT Head)
    1. Consult pediatric neurology
  3. Important Headache Red Flags in children
    1. Age <3 years old
    2. Recent onset within prior 6 months, with steadily worsening pattern in severity or frequency
    3. Early morning awakening with Headache or Vomiting
    4. Diplopia
    5. Headache worsens with straining
    6. Seizures
    7. Mood, mental status or school performance change
    8. Neurocutaneous Syndrome findings (e.g. Cafe-Au-Lait Macules)
  4. Predictors of space occupying lesion
    1. Headache worse with lying down or on awakening
    2. No Family History of Migraine Headache
    3. No visual symptoms
    4. Headache duration <6 months
    5. Vomiting
    6. Confusion
    7. Neurologic Exam abnormalities
    8. Medina (1997) Radiology 202: 819-324 [PubMed]
  5. Headaches are present in 62% of children with Intracranial Mass (99% have accompanying neurologic findings)
    1. History
      1. Vomiting (>72%)
      2. Personality or speech problems, developmental regression or problems in school (>81%)
      3. Weight loss (>66%)
        1. Review weight growth curve
      4. Difficulty walking for age over 2 years (>77%)
      5. Upper extremity weakness (>63%)
      6. Seizures (>6%)
      7. Diplopia in age over 4 years (>60%)
    2. Exam
      1. Lethargy or confusion (>72%)
      2. Papilledema (>65%)
      3. Head Tilt (>50%)
      4. Escalating Head Circumference (under age 3 years) or enlarging Fontanelle (under 2 years)
    3. References
      1. (1991) J Neuro-Oncol 10:31-46 [PubMed]
  • Exam
  1. See Headache Examination
  2. Consider obtaining Head Circumference in young children (age <3 years) or review growth curve
  3. Obtain Blood Pressure in children with Headache
    1. Hypertension may reflect undiagnosed renal disease or Aortic Coarctation
  4. Complete Neurologic Exam
  5. Fundoscopic Exam
  6. Skin Exam
    1. See Neurocutaneous Syndrome (e.g. Neurofibromatosis, Tuberous Sclerosis)
  • Evaluation
  1. See Headache History
  2. See Headache Examination
  3. See Headache Diagnostic Testing
  4. Consider Organic Headache
    1. Evaluate Headache Red Flags
    2. Headaches are uncommon in age <3 years and may have subtle presentations
      1. May present as episodic colic, Torticollis or decreased activity
  5. Headache Timing
    1. Acute Headache
      1. Acute Generalized Headache
      2. Acute Localized Headache
      3. Acute Recurrent Headache
    2. Chronic Headache
      1. Chronic Progressive Headache
      2. Chronic Non-Progressive Headache
  1. See Migraine Headache Diagnostic Criteria
  2. Migraine Headache may be diagnosed based on classic presentation with normal exam
  3. Family History increases likelihood of Migraine Headache
  • Management
  1. See Headache General Measures
  2. Consult pediatric neurology for Headache Red Flag findings
  3. Reassuring ED history and exam has a low rate of missed serous neurologic and non-neurologic causes of Pediatric Headache
    1. However, patients and their families should be made aware of return indications including red flags (return rate 3 to 12%)
    2. Hong (2019) Neurology 92(16): e1926-32 [PubMed]
    3. Zhou (2020) Pediatrics 146(5): e20201647 [PubMed]
  4. Treat specific Headache type
    1. See Migraine Headache Management in Children
    2. See Emergency Department Migraine Headache Care
    3. See Tension Headache
    4. See Medication Overuse Headache
  • References
  1. Fuchs and Yamamoto (2012) APLS, Jones and Bartlett, Burlington, p. 184-6
  2. Ramdhan (2023) Crit Dec Emerg Med 37(5): 23-9
  3. Lewis (2002) Am Fam Physician 65(4):625-32 [PubMed]
  4. Winner (1997) Postgrad Med 101(5):81-90 [PubMed]