Headache – Emergency management in children

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Key points

  • Headaches can be divided into primary disorders (commonly migraines) and secondary disorders (commonly caused by a viral illness but may include serious underlying pathology).
  • The test with the greatest reward in evaluation of headache is the history and examination.
  • The aim of the assessment is to differentiate children with red flags suggestive of serious underlying pathology (to enable specialist referral) from those who can be managed supportively without the need for investigations.
  • Simple analgesia is the recommended initial treatment for primary headache disorders followed by sumatriptan (if age greater than or equal to 6 years) and/or dopamine agonists (if age less than 12 years) if migraine is the likely diagnosis.
  • Opiates are not recommended for the treatment of primary headache disorders.

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland with a headache.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Neurology, Queensland Children’s Hospital, Brisbane. It has been endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Headaches can be divided into primary disorders (commonly migraines) and secondary disorders (commonly caused by a viral illness, but include serious conditions such as raised intracranial pressure, intracranial haemorrhage or infection). Headache may also be a manifestation of underlying mental health, substance abuse or psychosocial issues. Headaches in children reach a peak at approximately 11-13 years of age with migraine and tension type headaches as the most predominant forms1.

The pain of headache is not associated with the brain, meninges or skull as these structures do not have nociception.  Perception of pain arises from blood vessels (intra- & extracranial), cranial and spinal nerves, face, skull and neck muscles, and other skull structures (teeth, sinuses and ears).2

Headaches account for approximately 1% of paediatric ED presentations.2 Primary disorders represent about 40% and secondary disorders 60% of all paediatric headache presentations to ED. Serious underlying disease are found in 7-15% of paediatric headache presentations.3

Primary headache disorders

TypeDescriptionDurationFrequency
Tension headache
  • typically, bilateral, dull, deep or band like
  • mild to moderate in severity
  • not aggravated by exertion
 30 minutes to 7 days
Months/years if chronic 		Most common type of headache affecting patients of all ages.
Migraine without aura
  • at least two of the following:
    • bilateral or unilateral location
    • pulsating
    • moderate to severe pain
    • made worse with activity
  • at least one associated symptom including nausea, vomiting, photophobia and/or phonophobia
 1- 48 hours

Most common around 15 years of age (onset age 7 years in boys, 11 years in girls).

Prevalence of 3% at age 3-7 years, 4-11% at 7-11 years and 8-23% over 11 years.4

Migraine with aura An aura (perceptual disturbance that precedes onset of the headache) may consist of:
  • visual disturbance (e.g. scintillations, gleam of light, blurred vision, blind spots)
  • an odour
  • paraesthesia in the hand or face.

Generally consistent for an individual.

 Auras may occur from a few seconds to an hour before headache onset.
Cluster headache
  • typically occur as 5 or more episodes ranging from every other day to 8 in a single day.
  • severe, sharp stabbing pain on one side of the head
  • associated with autonomic symptoms (nasal stuffiness, rhinorrhoea, lacrimation, conjunctival injection, Horner’s syndrome) on the side of pain.
 15 minutes to 3 hours Rare in children under 12 years of age

Migraines

Migraines have a complicated pathophysiology including cranial vasodilation and sensitisation of trigeminovascular pathways. They are classified as simple or complicated based on their clinical presentation.

Complicated migraines include:

  • Migraine with brainstem aura- the aura is characterised by vertigo, ataxia, nystagmus, dysarthria, tinnitus/hyperacusis, bilateral parasthesias, diplopia or visual disturbance. The aura can be unilateral or bilateral but does not involve motor weakness and the accompanying headache often is occipital.
  • confusional migraine is characterised by altered mental status, often accompanied by aphasia or impaired speech and followed by a headache.
  • hemiplegic migraine is rare and is defined as a migraine with aura including motor weakness- characterised by prolonged hemiplegia, visual symptoms numbness, aphasia and confusion.

Episodes of complicated migraine, especially the initial episode, can be dramatic and will usually prompt presentation to an ED. In this initial presentation, complete evaluation including imaging is warranted (preferably MRI and MR angiogram) to exclude other causes including stroke, mass lesions and intoxication.

The criteria for a paediatric migraine diagnosis as defined by The International Headache Society6 includes at least five attacks of migraine without aura as described in table above, or at least two attacks of a migraine with one or more fully reversible aura symptoms which can include visual, sensory, speech and or language, motor, brainstem or retinal features with at least three of the following features:

  • at least one aura symptom that gradually spreads over ≥5 minutes
  • Two or more aura symptoms occur in succession
  • at least one aura symptom is unilateral – aphasia and dysarthria are regarded as this
  • aura present for less than one hour, motor symptoms for more than one hour
  • At least one aura symptom is positive- scintillations, parasthesia
  • headache accompanying or within one hour of aura

Secondary headache disorders

Serious causes of secondary headaches
Raised intracranial pressure
(mass effect due to tumour/cyst/vascular lesion, cerebral oedema or increase in fluid (CSF/hydrocephalus or blood) or idiopathic intracranial hypertension (see table below)
  • Headache is:
    • progressive
    • causing night wakening
    • worse with exercise and valsalva (sneezing, coughing, toileting)
    • associated with persistent vomiting
    • may be associated with neurological deficits (including lethargy and personality/behavioural change)
  • Specific physical signs can include gait/coordination disturbance, papilloedema, abnormal external ocular movements and pupillary responses (3rd, 4th and 6th nerve palsies).
  • Cushings triad (hypertension, bradycardia and respiratory depression) is a late phenomenon.
Intracranial infection
(including meningitis, encephalitis and brain abscess)
  • Headache is associated with fever, altered mental status, neck stiffness, photophobia, nausea/vomiting, pain with eye movements and neurological deficits.
  • More common in a child who is immunosuppressed or has a VP shunt.
Intracranial haemorrhage
  • The “thunderclap” headache is a classical feature but child typically presents with additional neurological signs.
  • Risk factors include congenital heart disease, AV malformations, sepsis, coagulation defects, brain tumours, meningitis, leukaemia, autoimmune disease and sickle cell disease.
Trauma
  • Post traumatic headaches develop within a week of injury.
  • Often associated with post-concussive symptoms (sleep, balance, cognitive and mood changes). Refer to Head Injury Guideline.
Ischaemic stroke
  • Headache associated with sudden onset of unilateral neurological symptoms that persist and do not progress to other side.
Venous thrombosis
  • Rare cause of headache with insidious onset that is usually associated with head/neck infection, severe dehydration or prothrombotic states, and may be associated with abnormal vision or focal weakness.
  • Risk factors include arteriopathies (eg. Moya-Moya, sickle cell), cardiac disease (PFO, arrythmia, congenital or acquired heart diseases), hypercoagulable states, chronic head and neck disorders including tumours, sepsis, genetic and metabolic conditions (eg. Trisomy 21, mitochondrial diseases)8
Other
  • Facial and eye conditions (including refractive error, glaucoma, optic neuritis, temporomandibular joint dysfunction, dental caries/abscess and sinusitis) and hypertension.
Idiopathic intracranial hypertension
Diagnostic Criteria9

Signs and symptoms of raised intracranial pressure

  • headache
  • transient visual disturbance
  • pulsatile tinnitus
  • gait instability
  • papilloedema

Absence of localising neurological signs (excluding cranial nerve palsies)

Normal CSF analysis

Elevated opening pressure ≥25cmH2O in non sedated or obese children

Normal to small ventricles on neuroimaging and absence of any tumour

Associated Conditions

Primary IIH

  • female sex
  • PCOS
  • obesity

Secondary IIH

Venous Anomalies & Obstruction

  • cerebral venous sinus thrombosis
  • SVC syndrome
  • brachiocephalic vein thrombosis
  • increased right heart pressure
  • Chiari malfomation
  • Intracranial mass or bleed
  • Hydrocephalus
  • Traumatic brain injury

Endocrine Disorders

  • Addison’s disease
  • hypoparathyroidism
  • Hypothyroidism

Drugs

  • corticosteroids (particularly withdrawal)
  • Growth Hormone, Progestogen, Levothyroxine
  • cytarabine, cyclosporine
  • lithium
  • antibiotics – sulfa, tetracycline
  • vitamin A and cis-retinoic acid
  • Phenytoin

Infectious diseases

  • CNS infection
  • HIV infection
  • Lyme disease
  • post varicella

Other medical conditions

  • anaemia
  • antiphospholipid antibody syndrome
  • Behcet’s disease
  • occult craniosynostosis
  • sarcoidosis
  • sleep apnoea
  • systemic lupus erythematosus
  • Trisomy 21
  • Vitamin A or D deficiency
  • MOG antibody disease

Assessment

The aim of the assessment is to exclude or identify red flags suggestive of serious underlying pathology to guide appropriate investigation (usually imaging) and treatment. Once a primary disorder diagnosis is established, questioning may differentiate migraine from other primary disorder types (refer to Introduction for descriptions of disorder types).

Appropriate management relies on a careful history and thorough examination.

History

History-taking should include specific questioning on:

  • pain (including nature, intensity and impact on normal activities including school, duration, exacerbating and relieving factors)
  • systemic symptoms
  • neurological symptoms
  • past medical history (including immunocompromising conditions, head injury, malignancy)
  • past surgical history (including VP shunt)
  • family history (including migraine history)
  • medications (including type, dose and frequency of medications for headache)
  • immunisations

Examination

Physical examination should include:

  • a thorough neurological examination including gait, coordination, fundi, external ocular movements and visual fields and fundoscopy
  • measurement of vital signs especially blood pressure
  • assessment of developmental milestones and growth
Red flags suggestive of serious underlying pathology
  • worsening headache with fever
  • sudden onset headache reaching maximum intensity within five minutes
  • new-onset neurological deficit (transient or sustained)
  • new-onset cognitive dysfunction or personality change
  • impaired level of consciousness
  • head trauma in previous three months
  • headache triggered by cough, valsalva, or sneeze
  • headache causing night wakening
  • early morning headache +/- vomiting
  • headache triggered by exercise
  • headache that changes with posture
  • clinical features of glaucoma
  • significant change in characteristics of headache
  • atypical aura
  • compromised immunity (e.g. HIV, on immunosuppressive drugs)
  • history of malignancy
  • vomiting without other obvious cause.

Seek senior emergency/paediatric advice as per local practice if red flags are identified.

Investigations

Investigations are not routinely required.

The presence of any red flags should prompt consideration of imaging and discussion with senior medical staff.  Blood tests may be helpful if considering intracranial infection (refer to Meningitis Guideline).

Management

Refer to flowchart [PDF 555.12 KB] for a summary of the emergency management and medications for children presenting with a headache:

Seek senior emergency/paediatric advice as per local practice if red flags suggestive of serious underlying pathology are identified on assessment.

Primary headache disorders

Alert

Opiates are not recommended in acute primary headache.

Simple analgesia is the recommended initial treatment for all primary headache disorders. Consider Ondansetron in a child with vomiting as part of the end points of headache reduction, nausea and vomiting reduction7.

Simple analgesia dosing in children
Paracetamol (Oral) 15 mg/kg to maximum of 1 g every four hours, maximum four doses in 24 hours
Ibuprofen (Oral) 10 mg/kg to maximum of 400 mg every six to eight hours, maximum three doses in 24 hours
Ondansetron for the management of vomiting in children
Dose

Given orally or sublingually at a dose of 0.15 mg/kg (maximum 8 mg).

Tablets and wafers are available in 4 mg and 8 mg doses. Recommended doses are as follows:

  • 8-15 kg: 2 mg oral liquid or sublingual halved
  • 15-30 kg: 4 mg oral liquid or sublingual
  • over 30 kg: 8 mg oral liquid or sublingual
Considerations Ondansetron prolongs the QT interval in a dose – dependent manner. Exercise caution in children who have or may develop prolongation of QTc (such as those with electrolyte disturbances, heart failure or on medications that may lead to a prolongation of the QTc).

Migraine

Options for the acute abortive management of migraine include simple analgesia, triptans and dopamine antagonists. Standardised combination therapy of these agents is used in some centres with clinical effect but there are no randomised controlled trials to support efficacy.5 Patients who are given opiates for acute primary headache have longer length of stay in ED and higher rates of return ED visits within seven days when compared to patients given non-opiate medications.6

Recommended treatment for the acute abortive management of migraine
AgeTreatment
<6 years Prochlorperazine (Stemetil) (IV) and simple analgesia
6 years and older Sumatriptan (intranasal) and simple analgesia
Most effective when given early7,10

The most investigated combination is Sumatriptan and NSAIDs which has been found to be the most effective7

Sumatriptan dosing for the acute abortive management of a migraine in children over 6 years
Sumatriptan (Intranasal*/PO) 10-20 mg into 1 nostril or ingested
May be repeated once, at least two hours after first dose if symptoms recur (maximum 40 mg in 24 hours)
Do not repeat dose during an attack if first dose ineffective.
Considerations Sumitriptan is non LAM for use in children between 6-12 years. Individual patient approval (IPA) would be required in this group.
Contraindications Ergotamine
Children with cardiac disease
SSRIs

*Intranasal sumatriptan is discontinued and supply is likely to be exhausted in 2024.

Dopamine antagonist dosing for the acute abortive management of a migraine in children
Prochlorperazine
(Stemetil) (IV)		 0.15 mg/kg (maximum 12.5 mg) as a slow IV push over 2-5 minutes
Followed by 20ml/kg sodium chloride 0.9% up to maximum of 1 L administered over one hour if deemed necessary.
Or Chlorpromazine
(Largactil) (IV)		 0.25 mg/kg in 10-20 mL/kg sodium chloride 0.9% up to maximum of 1 L administered over 30 minutes.

Higher rates of rescue medication, hospitalisation and clinically significant hypotension (despite co-administration of fluid) when compared with prochlorperazine.

Or Metoclopramide
(Maxolon) (IV)		 0.1-0.15 mg/kg (maximum) 10 mg

Give undiluted over 3 minutes or dilute to 200microgram/mL and infuse over at least 15 minutes.

Side effects of dopamine antagonists Extrapyramidal symptoms such as akathisia and dystonic reactions (see below)

Side effects of dopamine antagonists

Acute dystonia is a sustained or brief muscle contraction resulting in twisting movements or abnormal postures. Dystonia can be focal or generalised. It generally develops within minutes to days and affects the face, neck and trunk. Oculogyric crisis, laryngeal spasm and opisthotonus can occur.

Patients and/or caregivers should be specifically counselled about the potential for delayed onset of extrapyramidal symptoms following discharge. While rare, they warrant representation to ED for symptomatic treatment.

BenzAtropine dosing for the treatment of acute dystonia in children
BenzAtropine (IV/IM) 0.02 mg/kg (to maximum adult dose of 1 mg) in children aged more than three years. Give undiluted. IM route preferred. If IV route is necessary, give undiluted by rapid injection over at least 1 minute.
May repeat in 15 minutes.

Akathisia is an abnormal, uncomfortable sensation of restlessness combined with an urge to move about. On movement, the patient experiences some degree of relief.

Diazepam dosing for the treatment of acute akathisia in children
Diazepam (Oral) 0.04 – 0.2 mg/kg (to maximum adult dose of 2-10 mg) every eight to twelve hours.

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

Includes child with:
  • suspected underlying pathology
  • chronic symptoms
  • significant clinical concern not already described
Reason for contact Who to contact
Advice
(including management, disposition or follow-up) 		Options:
Referral First point of call is the onsite/local paediatric service

Inter-hospital transfers

Do I need a critical transfer?
Request a non-critical inter-hospital transfer
Non-critical transfer forms

Disposition

When to consider discharge from ED

Consider discharge for children with a primary headache disorder who have responded to treatment.

Parents/caregivers of a child who has suffered a migraine should receive education on how to manage future migraines (see Headaches and Migraines fact sheet), as well as specific information around extra pyramidal reactions if given Promethazine, Chlorpromazine or Metoclopramide.

Follow-up

If symptoms of primary headache recur, patients should see their GP to consider specialist referral.

When to consider admission

Admission to an inpatient service is recommended for a child with a primary headache disorder who fails to respond to treatment. In such cases, alternative diagnoses should be considered.

Children with suspected serious underlying pathology may require admission to an inpatient service, depending on the outcome of investigations.

  1. Emerging Pharmacological Treatments for Migraine in the Pediatric Population. Iannone, L.F.; De Cesaris, F.; Geppetti, P. Life 2022, 12, 536. https://doi.org/10.3390/ life
  2. Headaches in Childhood. Auckland : Starship Children’s Health, Pinnock, Dr Ralph.
  3. Pediatric migraine: abortive management in the emergency department. Sheridan, D.C., D.M. Spiro, and G.D. Meckler. 2, 2014, Headache, Vol. 54, pp. 235-45.
  4. Acute Headache in Children and Adolescents Presenting to the Emergency Department. Lewis, Donald W. 2000, Headache, Vol. 40, pp. 200-203.
  5. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Lewis, Donald W. 2004, Neurology, Vol. 63, pp. 2215-2224
  6. The International Headache Society. The International Classification of Headache Disorders 3rd Edition (ICHD-3) 2017/2018
  7. Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action. Ong JJY, De Felice M. Neurotherapeutics. 2018 Apr;15(2):274-290
  8. Acute Ischaemic Stroke in Childhood: A Comprehensive Review. Mastrangelo, M., Giordo, L., Ricciardo, G., De Michele, M., Toni, D., Leuzzi, V Eur J Paediatrics (2022), 181: 45-58
  9. Idiopathic Intracranial Hypertension in Children and Adolescents: An Update. Cleves-Bayon, C. Headache: The Journal of Head and Face Pain (2018), 58 (3): 485-493
  10. Effectiveness of Standardized Combination Therapy for Migraine Treatment in the Pediatric Emergency Department. Leung, Stephanie. 2013, Headache, Vol. 53, pp. 491-497.
  11. Comparison of parenteral treatments of acute primary headache in a large academic emergency department cohort. McCarthy, Lucas H. 2014, Cephalgia, Vols.

Document ID: CHQ-GDL-60017

Version number: 3.1

Supersedes: 3.0

Approval date: 14/03/2024

Effective date: 20/03/2024

Review date: 14/03/2028

Executive sponsor: Executive Director Medical Services

Author/custodian:  Queensland Emergency Care Children Working Group

Applicable to: Queensland Health medical and nursing staff

Document source: Internal (QHEPS) + External

Authorisation: Executive Director Clinical Services

Keywords: Headache, migraine, paediatric, emergency, guideline, children, 60017

Accreditation references: NSQHS Standards (1-8): 1, 4, 8

This guideline is intended as a guide and provided for information purposes only. View full disclaimer.

Last updated: March 2024