Headaches are a common complaint among children, with increasing frequency in adolescence. According to the Agency for Healthcare Research and Quality, more than 3 million Americans seek emergency care every year due to headaches, and one-third of them are attributable to migraines. Headaches have a significant impact on the lives of children and adolescents, resulting in school absence, decreased extracurricular activities, and poor academic achievement. Among patients, the spectrum of pathology varies widely, continually challenging healthcare providers to recognize serious, life-threatening conditions, while judiciously evaluating and treating all patients. This issue reviews the broad differential of primary and secondary headaches in the pediatric emergency department, summarizes effective strategies for diagnosis, and evaluates the current evidence supporting safe, appropriate treatment. As emergency clinicians treat increasingly more medically complex patients, they should be aware of the best current practices to evaluate and treat headaches in the pediatric population.
Key words: pediatric headache, primary headache, secondary headache, migraine, aura, tension-type headache, cluster headache, triptan, NSAID
A 14-year-old girl with no significant past medical history presents to your ED with a chief complaint of headache. She describes the pain as 9/10, bifrontal, and associated with nausea and photophobia. She denies fevers, recent illness, or any trauma. When you review her family history, you note that her mother suffers from frequent headaches. Her vital signs and physical exam are all within normal limits.
An 11-year-old boy presents to your ED with a persistent headache. His past medical history is notable for a helmet-to-helmet collision during a football game 1 month prior to presentation. Since that time, he has also complained of difficulty concentrating, dizziness, and fatigue. On your exam, you note a poorly cooperative boy with normal vital signs who is in no acute distress. He repeatedly asks you to lower your voice and refuses to cooperate with your ophthalmic exam. The remainder of your physical exam is unrevealing.
An 18-year-old male presents to your ED with severe headache and fever for the past 3 days. Your examination reveals an ill-appearing male with photophobia and neck stiffness.
How would you approach the evaluation and treatment of these headaches?
The presence of a severe headache is anxiety-provoking in both parents and children. When treating patients with headaches in the emergency department (ED), the primary objective of the emergency clinician is to promptly recognize the life-threatening conditions requiring immediate medical or operative management. In addition, appropriate assessment and treatment of less-severe headaches have the potential to prevent unnecessary hospital admissions. A recent study evaluating patients who presented to the ED with a chief complaint of headache demonstrated that the most common cause of headache was upper respiratory infection (19.2%). Migraines, posttraumatic headaches, and tension-type headaches accounted for 18.5%, 5.5%, and 4.6%, respectively. Serious, life-threatening headaches (4.1%) including meningitis (1.6%), acute hydrocephalus (0.9%), and tumors (0.7%) were lesscommon etiologies.1 For optimal assessment and management of headaches, emergency clinicians must be familiar with the broad clinical spectrum of etiologies for headache in the pediatric population.
Ninety-six percent of American adults report having had a headache in their lifetime, and nearly 40% have had a significant headache at some point.2 Among children, the prevalence of major headache ranges from 37% to 51% during the elementary school years and gradually rises to 57% to 82% by adolescence. Frequent or severe headaches (including migraines) were reported by 17% of participants in a national sample of children and adolescents.3 Headache ranks as the third leading cause of referral to a pediatric ED.4 The most common type of recurrent headache in childhood is migraine; in adolescence, tension headaches are the most common type of frequent headache.5
Estimates of the overall prevalence of headache in children vary among researchers. Secondary headaches are most frequently encountered before the age of 5 years; however, a primary headache (such as migraine) can occur as early as a few months of age. Chronic tension-type headache has been reported in 0.9% of 15-year-old children.6
In a widely cited study, Bille surveyed 8993 children aged 7 to 15 years and found that 59% had suffered headache at some time in their life.7 In a systematic questionnaire of 2941 children, Sillanpaa found the prevalence of headache to be 37% at age 7 years, increasing to 69% by 14 years; migraine accounted for 2.7% and 10.6% of these headaches, respectively.8
Studies have shown that up to 51% of children aged 7 years and 57% to 82% of adolescents aged 15 years report recurrent headaches.9,10 A study performed in Taiwan indicated that approximately 85% of children aged 13 to 15 years have had headache.11 According to a large survey by Split and Neuman, 75% of children have suffered headaches by age 15 years.12
A literature search was performed using the following databases: PubMed, Web of Science, Ovid MEDLINE ®, Cochrane Database of Systematic Reviews, and Scopus. Searches were limited to those published in English. Search terms included pediatric headache, child, children, emergency, primary headache, and secondary headache. Defining the specific type of headache further refined the search, using the terms migraine, aura, migraine equivalent, tension-type, cluster, posttraumatic, concussion, pseudotumor cerebri, intracranial hypertension, sinusitis, intracranial mass, medication overuse, seizure, infection, and meningitis. The search returned 12,155 abstracts that were reviewed for relevance. The bibliographies of the relevant articles were also reviewed for additional publications. In addition, guidelines from the Agency for Healthcare Research and Quality (AHRQ) through the National Guidelines Clearinghouse (www.guidelines.gov) were reviewed. Review of the literature revealed a tremendous body of data available from adult studies, from which pediatric treatments have been extrapolated. The pediatric literature is growing, and the available data from pediatric studies are reviewed in this article.
The greatest medical pitfall in pediatric headache management is failure to make an accurate diagnosis. Effective treatment of headache relies on identification of the underlying cause. In the setting of an abnormal physical examination or certain historical red flags, a headache must be considered a secondary headache until otherwise ruled out.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Michael J. Alfonzo, MD, MS; Kirsten Bechtel, MD; Shannon Babineau, MD
July 1, 2013