Residency · Residency · Medicine Pediatrics
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
Systemic symptoms or disease (fever, weight loss, malignancy); Neurologic signs (papilledema, focal deficits); Onset sudden (thunderclap headache); Onset after age 50 (or very young child); Pattern change, Positional, Precipitated by Valsalva, Progressive.
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.
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.
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.
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
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
- 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.
- American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache. 2019;59(1):1-18.
- Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: Evaluation of children and adolescents with recurrent headaches. Neurology. 2002;59(4):490-498.