Emergency Department Management of Primary Headache Disorders in Pediatric Patients (Pain Management CME and Pharmacology CME)

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Delivery Method:	Online
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Publication Date: January 2025 (Volume 22, Number 1)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 01/01/2028.

Specialty CME Credits:Included as part of the 4 credits, this CME activity is eligible for 2 Pain Management credits and 2 Pharmacology credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Headaches are a common reason for pediatric visits to the emergency department. Emergency clinicians must distinguish between common and dangerous secondary causes of headache and primary headache disorders such as migraine and tension-type headaches. This issue discusses the diagnosis of primary headaches by history and physical examination, the options for first-line treatment of primary headache and for severe or refractory migraines, and procedural interventions that may be considered when other therapies have failed. Guidance is provided for patient and family education regarding triggers, lifestyle modifications, and nutraceutical prophylaxis.

Case Presentations

An 11-year-old boy presents with the gradual onset of a severe throbbing bifrontal headache that started 12 hours ago...

• The boy complained of tingling on the right side of his face before the headache began, and he continues to complain of nausea. He has vomited twice. He spent most of the day in his room with the lights off. He has had several similar headaches in the past, but they lasted only a few hours and improved with ibuprofen and a nap.
• On review of symptoms, he denies any fever, infectious symptoms, or recent trauma, and has no significant past medical history. His examination is normal.
• What is the most likely diagnosis? Does he need blood tests or neuroimaging?

A 15-year-old girl presents with a prolonged and debilitating headache...

• The girl tells you the headaches have been occurring “a lot” for several months. At age 13 years, she was diagnosed with migraines and is followed by a family physician. Initially, her headaches responded to naproxen, and last year she was prescribed sumatriptan, which seemed to help, but in the last 6 months, she has had little relief with naproxen despite almost daily use, and the sumatriptan (which she takes only when she can no longer tolerate the pain) has not helped. Her current headache is similar to past migraines, but “nothing seems to work,” and the pain has been unremitting for 5 days. She denies focal neurologic, constitutional, or infectious symptoms.
• The girl appears uncomfortable, but her vital signs, general examination, and neurological examination are normal other than dry lips and allodynia of the scalp.
• What is your differential diagnosis? What abortive therapies might you consider, and how will you counsel her if she improves?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.