# Headache Evaluation and Management Across Ages

## Introduction

Headache is one of the most frequent complaints in both pediatric and adult medicine. While most headaches are **primary** (migraine, tension-type), the med-peds physician must reliably identify **secondary headaches** requiring urgent evaluation. Age influences presentation, differential diagnosis, and treatment options significantly.

## Classification

### Primary Headaches
**Migraine**: With or without aura; most common disabling primary headache. **Tension-type headache (TTH)**: Bilateral, pressing/tightening, mild-to-moderate intensity. **Cluster headache**: Unilateral, severe, with autonomic features; rare in children. **Trigeminal autonomic cephalalgias**: Includes cluster, paroxysmal hemicrania, SUNCT.

### Secondary Headaches
Intracranial pathology (tumor, hemorrhage, abscess); Infection (meningitis, sinusitis); Idiopathic intracranial hypertension (IIH); Medication overuse headache; Post-traumatic headache.

## Red Flags: When to Worry

### SNOOP4 Mnemonic
**S**ystemic symptoms or disease (fever, weight loss, malignancy); **N**eurologic signs (papilledema, focal deficits); **O**nset sudden (thunderclap headache); **O**nset after age 50 (or very young child); **P**attern change, **P**ositional, **P**recipitated by Valsalva, **P**rogressive.

### Pediatric-Specific Red Flags
Headache waking child from sleep; Morning headache with vomiting (suggests raised ICP); Increasing head circumference in infants; Change in school performance or personality.

![Diagram of red flag symptoms in headache evaluation](images/headache-red-flags.jpg)

## Migraine Across Ages

### Pediatric Migraine
Often **bilateral** (frontal or temporal) rather than unilateral. Shorter duration (as brief as 2 hours in children vs. 4 hours in adults) Prominent **nausea and vomiting**; photophobia may be inferred from behavior. Episodic syndromes associated with migraine: cyclic vomiting, abdominal migraine, benign paroxysmal vertigo.

### Adult Migraine
Typically unilateral, pulsating, moderate-to-severe; Duration 4-72 hours; Associated aura in ~25% (visual, sensory, language); Chronic migraine: headache on 15 or more days per month for >3 months.

### Migraine in Older Adults
New-onset migraine uncommon; investigate for secondary causes. Aura without headache may mimic TIA. Medication interactions are a major concern.

## Diagnostic Approach

### History
PQRST approach: Provocative/palliative factors, Quality, Radiation, Severity, Timing. Headache diary: frequency, triggers, medications used, functional impact. Family history (strong genetic component in migraine)

### Examination
Fundoscopic exam for **papilledema**. Complete neurologic examination including gait. Blood pressure measurement (hypertensive headache)

### Imaging
**Neuroimaging not routinely indicated** for recurrent headaches with normal exam. MRI brain with and without contrast for red flag features. CT head for acute thunderclap headache; CT angiography for vascular concerns. LP after imaging if IIH or meningitis suspected.

![MRI showing idiopathic intracranial hypertension with empty sella](images/iih-mri.jpg)

## Treatment

### Acute Migraine Therapy

| Agent | Pediatric Use | Adult Use |
|---|---|---|
| Ibuprofen | First-line (10 mg/kg) | First-line (400-800 mg) |
| Acetaminophen | Alternative first-line | Alternative first-line |
| Triptans | Almotriptan (FDA-approved age 12+) | Sumatriptan, rizatriptan, others |
| Antiemetics | Ondansetron, prochlorperazine | Metoclopramide, prochlorperazine |

### Preventive Therapy
Indicated when headaches occur 4+ days/month with significant disability. **Pediatric options**: Amitriptyline, topiramate, propranolol (evidence is limited) **Adult options**: Topiramate, propranolol, amitriptyline, valproate. **CGRP monoclonal antibodies**: Erenumab, fremanezumab, galcanezumab (adults; emerging pediatric data)

### Non-Pharmacologic Approaches
Cognitive behavioral therapy; Biofeedback; Regular sleep, exercise, hydration; Identification and avoidance of triggers.

## Medication Overuse Headache

Occurs with analgesic use on 15+ days/month (simple analgesics) or 10+ days/month (triptans, opioids) **Treatment**: Education, gradual withdrawal, bridge therapy, preventive initiation. Increasingly recognized in adolescents.

![Chart comparing pediatric vs adult migraine features](images/migraine-comparison-ages.jpg)

## Clinical Pearls

Bilateral headache in children does not exclude migraine; pediatric migraine criteria differ from adult. Always perform fundoscopic exam; papilledema requires urgent neuroimaging and LP. Medication overuse headache is a treatable cause of chronic daily headache in both adolescents and adults. Avoid opioids for headache management in all age groups. CGRP inhibitors represent a paradigm shift in adult migraine prevention with excellent tolerability.

## References

1. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. *Cephalalgia*. 2018;38(1):1-211.
2. Powers SW, Coffey CS, Chamberlin LA, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine (CHAMP). *N Engl J Med*. 2017;376(2):115-124.
3. American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. *Headache*. 2019;59(1):1-18.
4. Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: Evaluation of children and adolescents with recurrent headaches. *Neurology*. 2002;59(4):490-498.