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.
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.
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).1
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
- 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
- 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.
- 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 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:
- basilar migraine – 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 characterised by prolonged hemiplegia, 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 defined by The International Headache Society includes at least five attacks of migraine without aura as described in table above, or at least two attacks of a migraine with aura with at least three of the following features:
- gradual development of autonomic aura
- aura that is fully reversible
- aura is present less than one hour
- headache within one hour of aura
Secondary headache disorders
|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:
- 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.
(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 child who is immunosuppressed or has a VP shunt.
- 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.
- 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.
- Headache associated with sudden onset of unilateral neurological symptoms that persist and do not progress to other side.
- 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.
- Requires specific neuroimaging (CT venogram or MR venogram) for diagnosis.
- Facial and eye conditions (including refractive error, glaucoma, optic neuritis, temporomandibular joint dysfunction, dental caries/abscess and sinusitis) and hypertension.
|Obstruction of venous drainage
- cerebral venous sinus thrombosis
- brachiocephalic vein thrombosis
- increased right heart pressure
- Addison’s disease
- thyroid replacement
- corticosteroids (particularly withdrawal)
- Growth Hormone, Progestogen, Levothyroxine
- cytarabine, cyclosporine
- antibiotics – sulfa, tetracycline
- vitamin A and cis-retinoic acid
- HIV infection
- Lyme disease
- post varicella
|Other medical conditions
- antiphospholipid antibody syndrome
- Behcet’s disease
- occult craniosynostosis
- sleep apnoea
- systemic lupus erythematosus
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-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)
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
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).
Refer to flowchart for a summary of the emergency management and medications for children presenting with a headache.
Primary headache disorders
Simple analgesia is the recommended initial treatment for all primary headache disorders. Consider Ondansetron in a child with vomiting.
||15 mg/kg to maximum of 1 gm every four hours, maximum four doses in 24 hours
||10 mg/kg to maximum of 400 mg every six to eight hours, maximum three doses in 24 hours
||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
- 15-30 kg: 4 mg
- over 30 kg: 8 mg
||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).
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
|Less than 12 years
||Prochlorperazine (Stemetil) (IV) and simple analgesia
|12 years and older
||Sumatriptan (intranasal) and simple analgesia
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.
Children with cardiac disease
|0.15 mg/kg (maximum 12.5 mg) in 20 mL/kg sodium chloride 0.9% up to maximum of 1 L administered over one hour.
|0.25 mg/kg in 20 mL/kg sodium chloride 0.9% up to maximum of 1 L administered over one hour.
Higher rates of rescue medication, hospitalisation and clinically significant hypotension (despite co-administration of fluid) when compared with prochlorperazine.
|0.2 mg/kg (maximum) 10 mg
|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.
||0.02 mg/kg (to maximum adult dose of 1 mg) in children aged more than three years.
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.
||0.04 – 0.2 mg/kg (to maximum adult dose of 2-10 mg) every eight to twelve hours.
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
(including management, disposition or follow-up)
- onsite/local paediatric service
- Queensland Children’s Hospital experts via Children’s Advice and Transport Coordination Hub (CATCH) on 13 CATCH (13 22 82)
- local and regional paediatric videoconference support via Telehealth Emergency Management Support Unit TEMSU (access via QH intranet) on 1800 11 44 14 (24-hour service)
||First point of call is the onsite/local paediatric service
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 Factsheet), as well as specific information around extra pyramidal reactions if given Promethazine, Chlorpromazine or Metoclopramide.
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.