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

Table of Contents

 

About This Issue

Headache is the most common neurological symptom in children and a common presentation to the emergency department (ED). Diagnosis of primary headache relies on an understanding of the diagnostic criteria of primary headache disorders and a thorough history and physical examination to identify red-flag features suggestive of a secondary headache. Unfortunately, studies have documented significant practice variability in the ED, with high rates of unnecessary neuroimaging and unindicated therapy with opioids. This issue provides an evidence-based review of pediatric primary headache disorders and offers guidance for management in the ED. In this issue, you will learn:

The relationship between the pathophysiology and clinical aspects of primary headache disorders

The differential diagnosis of pediatric primary headache disorders

Major categories of life-threatening etiologies of secondary headaches and associated red-flag symptoms

Key components of the history and examination in the evaluation of headaches in the ED

International Classification of Headache Disorders diagnostic criteria for pediatric primary headache disorders

Types of complex migraines with clinical features that mimic serious secondary headaches

In which cases diagnostic studies are indicated

Recommendations for treatment of migraines, tension-type headaches, and cluster headaches

Cutting edge treatments that may be effective for acute treatment of pediatric primary headache disorders

Recommendations for disposition, including discharge counseling and resources for patients and families

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology, Etiology, and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. Initial Stabilization
   2. History
      1. Headache History
         1. Headache Characteristics
         2. Associated Symptoms
         3. Prior Headaches
      2. Past Medical and Social History
      3. Medications
      4. Family History
   3. Physical Examination
10. Diagnostic Studies
    1. Imaging Studies
    2. Electrocardiogram
11. Treatment
    1. Migraine Treatment
       1. Analgesics/Nonsteroidal Anti-inflammatory Drugs
       2. Triptans
       3. Dopamine Antagonists
       4. Ondansetron
       5. Corticosteroids
       6. Valproate Sodium
       7. Dihydroergotamine
       8. Magnesium Sulfate
       9. Opioids
    2. Tension-Type Headache
    3. Cluster Headache
12. Special Populations
    1. Headaches in Reproductive-Age Females
    2. Headaches in Children With Medical Comorbidities
13. Controversies and Cutting Edge
    1. Low-Dose Propofol
    2. Ketamine
    3. Calcitonin Gene-Related Peptide-Related Therapies
    4. 5-HT1F Receptor Agonists
    5. Nerve Blocks and Trigger Point Injections
       1. Nerve Blocks
          1. Greater Occipital Nerve Block
          2. Sphenopalatine Ganglion Nerve Block
          3. Additional Considerations
       2. Trigger Point Injections
    6. Neuromodulation
14. Disposition
    1. Admission Criteria
    2. Discharge Criteria
    3. Discharge Counseling
15. Summary
16. Time- and Cost-Effective Strategies
17. 5 Things That Will Change Your Practice
18. Risk Management Pitfalls for Managing Pediatric Primary Headaches
19. Case Conclusions
20. Clinical Pathway for Emergency Department Management of Pediatric Migraine
21. Tables and Figures
22. References

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?

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Irwin SL, Greene KA, Pavitt SJ, et al. Headache in the pediatric population: focus on migraine. Semin Neurol. 2022;42(4):479-488. (Review) DOI: 10.1055/s-0042-1757927

4. * Raucci U, Della Vecchia N, Ossella C, et al. Management of childhood headache in the emergency department. Review of the literature. Front Neurol. 2019;10:886. (Review) DOI: 10.3389/fneur.2019.00886

6. * Camargo A, Kanekar S. Neuroimaging in pediatric headache. Neurol Clin. 2022;40(3):679-698. (Review) DOI: 10.1016/j.ncl.2022.02.007

14. * Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: acute treatment of migraine in children and adolescents: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Headache. 2019;59(8):1158-1173. (Practice guideline) DOI: 10.1111/head.13628

17. * Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002;59(4):490-498. (Practice guideline) DOI: 10.1212/wnl.59.4.490

26. * Vuralli D, Ozge A, Bolay H. Pediatric headache. In: Togha M, Jafari E, Mohammadianinejad SE, et al, eds. Headache and Migraine in Practice: Academic Press; 2022:239-263. (Book chapter) ISBN: 9780323997294

27. * Ghosh A, Silva E, Burish MJ. Pediatric-onset trigeminal autonomic cephalalgias: a systematic review and meta-analysis. Cephalalgia. 2021;41(13):1382-1395. (Systematic review and meta-analysis; 86 studies) DOI: 10.1177/03331024211027560

30. * Baglioni V, Orecchio S, Esposito D, et al. Tension-type headache in children and adolescents. Life (Basel). 2023;13(3). (Review) DOI: 10.3390/life13030825

38. * Cortel-LeBlanc MA, Orr SL, Dunn M, et al. Managing and preventing migraine in the emergency department: a review. Ann Emerg Med. 2023;82(6):732-751. (Review) DOI: 10.1016/j.annemergmed.2023.05.024

50. * Tsze DS, Ochs JB, Gonzalez AE, et al. Red flag findings in children with headaches: prevalence and association with emergency department neuroimaging. Cephalalgia. 2019;39(2):185-196. (Prospective cohort; 224 patients) DOI: 10.1177/0333102418781814

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Keywords: primary headache, serious secondary headaches, red-flag symptoms, migraine, migraine with aura, migraine without aura, pediatric migraine, cluster headache, trigeminal autonomic cephalalgias, recurrent headaches, tension-type headache, headache history, headache characteristics, triptans, dopamine antagonists, ergotamine, nerve blocks, trigger point injections, ketamine, calcitonin gene-related peptide-related therapies, CGRP, nutraceuticals