Residency · Residency · Medicine-Pediatrics

Headache Evaluation and Management Across Ages

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Alright, intern. You're exhausted, I get it. But before you dive into the labyrinth of headache protocols, let's simplify. When that patient rolls in clutching their head, your brain should immediately flip to two modes: "Is this going to kill them?" and "Can I make them feel better right now?" That's it. Forget the fancy classifications for a minute. Your initial job is to sniff out the truly dangerous stuff – the brain tumor, the bleed, the meningitis – because missing those is career-ending. If the headache started like a clap of thunder, if they have a fever and stiff neck, or if they can't move one side of their body, you're not ordering an Advil. You're getting a stat head CT and calling neurosurgery or infectious disease.

If those really scary "red flags" aren't waving in your face, then you can breathe a tiny sigh of relief. Most headaches are just migraines or tension headaches, even the really bad ones. Your next step is to make them comfortable. For adults and kids, a good dose of ibuprofen or naproxen is usually your first go-to. If it's a classic migraine, sometimes a triptan – like sumatriptan – can be a lifesaver, but be mindful of who you're giving it to, especially in younger kids. Don't forget the nausea; a little antiemetic can work wonders. The rest – the detailed diary, the complex preventive medications, the deep dive into triggers – that's for the light of day, for clinic, for someone who isn't running on three hours of sleep. Just keep them safe and comfortable.

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

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

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.

For the intern

At 3am, your primary job is ruling out dangerous secondary headaches. Check vital signs, perform a thorough neurologic exam including fundoscopy for papilledema, and obtain stat neuroimaging if any SNOOP4 red flags are present—sudden thunderclap onset, fever with nuchal rigidity, new focal deficits, or progressively worsening pattern. Treat acute migraine with ibuprofen 10 mg/kg (pediatrics) or 600–800 mg (adults) plus an antiemetic like ondansetron. The detailed headache diary, trigger identification, and preventive therapy discussions can wait until morning rounds when the patient is more comfortable and you're more coherent.

Common pitfalls

• Assuming unilateral headache is required for pediatric migraine—children commonly have bilateral frontal or temporal pain, and using adult criteria will cause you to miss the diagnosis.
• Ordering routine neuroimaging on stable patients without red flags—this yields low-value false positives and increases anxiety; reserve MRI for abnormal exams or SNOOP4 features.
• Missing medication overuse headache in adolescents—teens taking ibuprofen or excedrin daily for school-related headaches often worsen their condition; ask specifically about analgesic frequency.
• Forgetting fundoscopy—papilledema from idiopathic intracranial hypertension or tumor can present with isolated headache and normal mental status, but you'll miss it without looking at the optic discs.

Make it stick

You're a junior resident covering the pediatric floor overnight. A 14-year-old girl is admitted with a "worst headache of my life." She describes it as throbbing behind her right eye, 9/10 pain, associated with nausea and light sensitivity. Her mom mentions she's been getting headaches more frequently lately, using ibuprofen almost daily. On exam, she's photophobic, but your neuro exam is normal, including fundoscopy. You give her a dose of ibuprofen and ondansetron, which helps. During your morning write-up, you realize she fits criteria for both migraine and medication overuse headache. This patient highlights the importance of a detailed history, including medication use, even in acute presentations, and the need to consider primary headache diagnoses while ruling out secondary causes.

If you remember one thing

Always perform a fundoscopic exam to rule out papilledema in any patient presenting with headache, as this can be the sole objective sign of life-threatening intracranial pathology. And remember, headaches in children can often be bilateral, so don't dismiss migraine just because the pain isn't unilateral.

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