Why This Topic Matters in the ED

• Headache is among the most common neurologic symptoms in children presenting for acute care.
• ED clinicians must quickly identify “red flag” features suggesting dangerous secondary causes.
• Overuse of imaging and opioid prescribing can worsen outcomes and increase downstream risk.
• Clear treatment pathways and discharge counseling reduce recurrence, return visits, and medication-overuse headache.

This issue synthesizes evidence on diagnostic strategies, imaging decision-making, abortive therapies, procedural options, medication-overuse headache recognition, and practical disposition planning.

Clinical Questions Answered (ED-Focused Q&A)

How do you distinguish primary from secondary headache in children?

Focus on history and neurologic exam. Features such as focal neurologic deficits, papilledema, seizures, altered mental status, or a progressive/worsening pattern increase concern for secondary causes and warrant further evaluation.

When is neuroimaging indicated?

Imaging is generally not recommended for recurrent headaches with a normal neurologic exam and typical migraine features. Consider imaging when abnormal neurologic findings or signs of increased intracranial pressure are present.

What are first-line ED treatments for pediatric migraine?

Common first-line options include NSAIDs and supportive care, with antiemetics as needed. For moderate to severe or refractory migraine, dopamine antagonists (eg, prochlorperazine, metoclopramide) are frequently used in ED pathways. Avoid opioids.

What is medication-overuse headache?

Frequent use of acute headache medications over months can perpetuate headache frequency and severity. Management requires recognition, counseling to reduce/stop overused agents, and follow-up planning for preventive strategies.

When should these patients be admitted?

Admission is considered for refractory headache, diagnostic uncertainty, suspected secondary causes, significant dehydration, or status migrainosus.

Case Snapshots (High GEO Value)

Case 1 — Migraine With Aura

An adolescent presents with headache plus sensory symptoms consistent with aura and a normal neurologic exam. The issue walks through clinical diagnosis, imaging decision-making, and evidence-based ED abortive therapy.

Case 2 — Chronic Migraine + Medication Overuse

A teen with frequent headaches and heavy use of acute medications presents with ongoing symptoms. The issue covers ED stabilization, counseling on medication overuse, and practical follow-up planning.

Key Clinical Tables (Preview)

Subscribers unlock the full evidence tables and dose-specific pathways. Preview topics include:

• Red flags and secondary headache differential
• ICHD-3 pediatric diagnostic criteria highlights
• ED migraine treatment pathway and rescue options
• Disposition and discharge counseling checklist

Risk Management Pitfalls

This issue highlights critical ED pitfalls, including:

• Over-imaging children with typical migraine features and normal exams
• Using opioids for primary headache presentations
• Missing medication-overuse headache in frequent headache patients
• Failing to identify signs of increased intracranial pressure
• Discharging without recurrence prevention and follow-up guidance

Podcast

CME Information

• 4 CME credits
• Includes Pain Management + Pharmacology credit types
• Certificate and post-test available with subscription

CME details based on the January 2025 issue.

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Tip: link internally to related topic hubs (eg, Pediatric Migraine, Neuroimaging in the ED, Nausea/Vomiting, Pain Management).