Management Of Headache In The Pediatric Emergency Department

Management Of Headache In The Pediatric Emergency Department

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentation
  3. Introduction
    1. Prevalence Of Headache
  4. Critical Appraisal Of The Literature
  5. Classification Of Headache Disorders
    1. Primary Headache
      1. Migraine Headache
      2. Migraine Without Aura
      3. Migraine With Aura
      4. Rare Forms Of Migraine
      5. Tension-Type Headache
      6. Cluster Headache
  6. Pathophysiology
    1. Primary Headache
      1. Migraine
      2. Cortical Spreading Depression
      3. Genetic Predisposition
      4. Tension-Type Headache
      5. Cluster Headache
    2. Secondary Headache
      1. Posttraumatic Headache
      2. Other Causes
  7. Differential Diagnosis
  8. Emergency Department Evaluation
    1. History
    2. Disease-Specific History Findings
      1. Migraine Headache
      2. Tension-Type Headache
      3. Cluster Headache
      4. Sinus Headache
      5. Head Trauma/Posttraumatic Headache
      6. Intracranial Masses
      7. Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)
      8. Malignant Hypertension
      9. Meningitis
      10. Epilepsy
      11. Medication Overuse Headache
    3. Physical Examination
  9. Diagnostic Studies
    1. Brain Imaging
      1. Imaging Recommendations For Primary Headaches:
      2. Imaging Recommendations For Secondary Headaches:
    2. Laboratory Studies
      1. Lumbar Puncture
  10. Treatment
    1. General Principles
    2. Disease-Specific Pharmacological Interventions
      1. Abortive Pharmacological Interventions For Migraine
        • Nonsteroidal Anti-Inflammatory Drugs And Acetaminophen
        • Dopamine Receptor Antagonists
        • Triptans
        • Dihydroergotamine
      2. Prophylactic Pharmacological Interventions For Migraine
      3. Tension-Type Headache Treatment
      4. Cluster Headache Treatment
      5. Secondary Headache Treatment
        • Sinusitis Treatment
        • Medication Overuse Headache Treatment
        • Intracranial Space-Occupying Lesion Treatment
        • Idiopathic Intracranial Hypertension Treatment
        • Malignant Hypertension Treatment
        • Meningeal Inflammation Treatment
        • Postlumbar Puncture Headache Treatment
  11. Controversies And Cutting Edge
    1. Intranasal Ketamine
    2. Low-Dose Propofol
  12. Disposition
    1. Indications For Referral
    2. Criteria For Admission
    3. Complications
    4. Prognosis
    5. Patient Education
  13. Summary
  14. Clinical Pathway For Diagnosis Of Pediatric Headache In The Emergency Department
  15. Clinical Pathway For Treatment Of Pediatric Primary Headache
  16. Risk Management Pitfalls For Pediatric Headache Managment
  17. Time- And Cost-Effective Strategies
  18. Case Conclusions
  19. Tables
    1. Table 1. International Headache Society Diagnostic Criteria: Migraine Without Aura
    2. Table 2. International Headache Society Diagnostic Criteria: Migraine With Aura
    3. Table 3. International Headache Society Diagnostic Criteria: Tension-Type Headache
    4. Table 4. International Headache Society Diagnostic Criteria: Cluster Headache
    5. Table 5. Typical Primary Headache Characteristics
    6. Table 6. Differential Diagnosis For Pediatric Headache
    7. Table 7. Factors Known To Precipitate Migraine Headaches
  20. References


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

Case Presentation

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.

Prevalence Of Headache

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

Critical Appraisal Of The Literature

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 ( 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.

Risk Management Pitfalls For Pediatric Headache Managment

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.

  1. “I thought the teenager with unilateral facial numbness was having an atypical migraine, so I sent her home with a triptan and told her to follow up with her pediatrician.” Careful history-taking and thorough neurological examination can help make the correct diagnosis. A high index of suspicion is needed to avoid missing a secondary headache. Remember that primary headaches are diagnoses of exclusion.
  2. “The patient was really sick and I didn’t want to sterilize the cultures, so I made sure to perform the lumbar puncture before giving antibiotics.” When faced with a decompensating patient with possible meningitis, do not delay the administration of life-saving antibiotics. Lumbar puncture is meant to aid in diagnosis; if you already know the treatment is needed urgently, do not wait.
  3. “The patient has a history of multiple concussions, so I figured his progressively worsening headache was just part of a posttraumatic headache.” Concussions and previous head injuries can be challenging to manage, but it is important to recognize acute on chronic changes or progression of symptoms as possible clues to more ominous pathology such as intracranial hemorrhage or venous thrombosis.
  4. “The patient was only 13, so I didn’t bother to check a urine pregnancy test.” Among female adolescents who are of childbearing age, eclampsia must be considered until pregnancy has been ruled out. In addition, some migraine medications, such as triptans and DHE, are contraindicated or discouraged in pregnancy. Urine pregnancy tests are inexpensive, readily available in the ED, and generally more reliable than the average teenager.
  5. “The patient has had the same headache for 2 months, so I got a head CT to find out why.” Chronic headaches without progression of symptoms or other red flags do not always require emergent head imaging. In fact, an MRI (which can be arranged as an outpatient) may provide a more thorough evaluation and avoid unnecessary exposure to ionizing radiation.
  6. “He said he gets sinus headaches all the time, so I gave him a prescription for amoxicillin and sent him on his way.” Sinusitis can cause headache; however, these patients are more likely to suffer from under-recognized primary headaches such as migraines and tension-type headaches. Judicious use of antibiotics is necessary to prevent resistance, and diagnosis-specific medications are important to address the pain.
  7. “The patient was in so much pain, I had to give him additional doses of morphine.” Narcotics play little role in the management of headaches and no role in the management of primary headaches. They may provide a quick fix, but this effect is fleeting and is typically followed by rebound headaches that have been recognized as medication overuse headaches.
  8. “He kept saying his headaches bothered him the most in the mornings – I thought he just didn’t want to go to school.” Early-morning headache is a red flag for an intracranial space-occupying lesion. A thorough history and physical examination should help differentiate this worrisome secondary headache from behavioral misconduct. Beware of drawing such conclusions before life-threatening pathology has been effectively ruled out.
  9. “She had papilledema on examination after a fall from a 3-story window, so I ordered an MRI right away.” A good fundoscopic examination should be performed on every patient. Since papilledema may suggest increased intracranial pressure, it is important to remember that timeliness is key. Even if MRI is available, if you have concern for an acute bleed with potential for rapid decompensation, CT would be your imaging modality of choice.
  10. “This was her third visit to the ED with status migrainosus in the last 2 months, so I started her on cyproheptadine to prevent a fourth visit.” Evidence for use of migraine prophylaxis in children is poor. If indicated, migraine prophylaxis should be administered by the patient’s medical home (primary care provider or neurologist) with a plan in place for good follow-up care. Lack of follow-up when starting chronic medications may lead to medication overuse or hazardous, unchecked medication side effects.


Table 1. International Headache Society Diagnostic Criteria: Migraine Without Aura

Table 2. International Headache Society Diagnostic Criteria: Migraine With Aura

Table 3. International Headache Society Diagnostic Criteria: Tension-Type Headache

Table 4. International Headache Society Diagnostic Criteria: Cluster Headache


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.

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  78. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications. Headache. 2012;52(3):467-482. (Review)
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Publication Information

Michael J. Alfonzo, MD, MS; Kirsten Bechtel, MD; Shannon Babineau, MD

Publication Date

July 1, 2013

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