Headache – Emergency management in children

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

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

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).

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

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

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.

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

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

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.

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

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.

Inter-hospital transfers

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.

Related documents

• Headaches and Migraines fact sheet
• Headache Diary [PDF]