Headache

Please remember there is a Paediatric Clinical Mailbox that can be used for any non-urgent queries: clinical_paediatrics_crosshousehospital@aapct.scot.nhs.uk

Headache is common in children, increasing in incidence from early childhood to adolescence. 

Primary Headache – Has no specific underlying cause, most common cause of chronic headaches in children. This includes migraine and tension-type headache.

Secondary Headache – Due to an underlying cause. This includes trauma, sinusitis, raised ICP, hypertension, substance use or its withdrawal.  This is less common in children.

Chronic Headache – >15 days per month > 3 months. Can be due to any primary or secondary headache type.

History

• Past history – including childhood periodic syndromes – colic, benign paroxysmal torticollis, BPV, cyclical vomiting, abdominal migraine.
• Growth, development and puberty.
• Systemic enquiry – features of systemic disease.
• Drug history – prescription, OTC, Illicit – consider medication overuse.
• Lifestyle – sleep, eating and drinking, screen time, exercise.
• Family history.
• Psychosocial and emotional history – anxieties, pressures, school/friends/academic performance, family structure and events.

Children with primary headache are more likely to exert self-imposed pressure and have depression, anxiety and somatisation that interfere with home, learning, and friendships.

Examination

• Weight/height/BMI/OFC/pubertal status
• HR and BP
• Skin – neurocutaneous stigmata, deliberate self harm
• Scalp and face – tenderness
• Neck – range of movement, neck muscle tenderness
• Local pathology – dental, eye, sinuses, ENT, TMJ
• Neurological examination.

Red Flags

When to refer

• Red flags in history or examination
• Concern about secondary headaches
• Ongoing management and treatment advice
• Progressively severe headaches.

Referrals to Paediatrics should be made via the SCI Gateway.

Please note, these are vetted in a timely manner so the priority status of a referral may change upon review.

General management of primary deadache

• As full participation in work and play activities as possible.
• Regular and sufficient sleep with limitation of screen time.
• Regular rest.
• Regular meals – especially breakfast.
• Adequate hydration – suggested daily volumes are
  • Age 1-2yrs: 900ml
  • Age 2-3yrs: 1L
  • Age 4-8yrs: 1.2L
  • Age 9-13yrs: boys 1.6L, girls 1.5L
  • Over 13yrs: boys 2L, girls 1.6L.
• Regular exercise.
• Avoid restriction of activity/food/drink unless evidence this is a trigger.
• Medication overuse counselling – paracetamol or ibuprofen for >15 days/month over past 3 months; other analgesics for >10 days/month over past 3 months.

Optician review.

Migraine

Common, can occur at any age.

Can be short lasting, more likely to be bilateral than adults.

May have a history of childhood periodic syndromes.

Can be familial, including familial hemiplegic migraine.

Triggers – physiological, environmental, emotional/psychological, dietary.

Avoid aggravating factors – headache diary can help identify these.

Pharmacological management

• Paracetamol/ibuprofen.
• Triptans
  • Contraindicated in hemiplegic migraine
  • For migraine with or without aura in combination with NSAID/paracetamol
  • Nasal faster onset, easier if vomiting
  • Nasal may produce an unpleasant taste/feeling
  • Can try alternative formulations/triptans.
• Antiemetic e.g. prochlorperazine.
• Consider prophylaxis if missing >2 days/month of school – propranolol or amitriptyline.

• The Brain Tumour Charity. Better safe than tumour.
• The Migraine Trust - general overview for families.
• NICE Clinical Knowledge Summaries. Scenario: young people aged 12-17 years. Last revised February 2024.
• Howells, R. Headache in childhood and adolescence.  Paediatric Neurology 2010: 10(5) 27- 29.
• Dooley JM, Gordon KE, et al. The utility of the physical examination and investigations in the paediatric neurology consultation.  Paediatr Neurol 2003 Feb; 28(2):96-99.
• Abu-Arafeh I and MacLeod S. Serious neurological disorders in children with chronic headache.  Arch Dis Child 2005 Sep; 90(9): 937-940.
• Strine TW, Okoro CA, et al. The associations among childhood headaches, emotional and behavioural difficulties, and health care use.  Pediatrics 2006 May; 117(5): 1728-1735.
• Whitehouse, WP, Agrawal S. Management of children and young people with headache.  Arch Dis Child Educ Pract Ed 2017; 102: 58-65.