Headache in Pediatrics

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Sequential Approach

The diagnosis of headache in children is mainly clinical. Follow these steps for a structured evaluation.

1

Detailed Anamnesis

Investigate the characteristics of pain (ALICIA: Occurrence, Location, Intensity, Character, Irradiation, Relief/Aggravating), associated symptoms, frequency, duration and triggering factors.

2

Complete Physical Examination

It includes neurological examination (cranial nerves, fundus, strength, sensitivity, reflexes, gait, cerebellum), measurement of blood pressure and head circumference in infants.

3

Search for Red Flags

Identify symptoms or signs that suggest a serious secondary cause. The presence of these signs modifies the study plan. See warning signs.

4

Classification and Diagnosis

If there are no warning signs, classify the headache as primary (migraine, tension) and establish a therapeutic plan. If there are doubts or warning signs, consider additional tests.

Types of Primary Headache

Migraine

Recurrent headache of moderate-severe intensity. In children it is usually bilateral (frontal/temporal) and of shorter duration than in adults.

Clinical Features:

  • Pain: Pulsatile, worse with physical activity.
  • Duration: 2 to 72 hours.
  • Associated symptoms: Nausea, vomiting, photophobia, phonophobia.
  • Aura (25% cases): Transient neurological symptoms (visual, sensory) that precede or accompany the headache.

Diagnostic Criteria (ICHD-3):

  • At least 5 episodes that meet the following criteria.
  • Duration of 2-72h.
  • At least 2 of: bilateral/unilateral, pulsatile, moderate/severe intensity, aggravated by physical activity.
  • At least 1 of: nausea/vomiting, photophobia/phonophobia.

Tension Headache

It is the most common primary headache. Generally related to stress or muscle tension.

Clinical Features:

  • Pain: Oppressive, not pulsatile, like a "band or helmet."
  • Location: Bilateral, holocranial.
  • Intensity: Mild to moderate.
  • Physical activity: It doesn't get worse with exercise.
  • Associated symptoms: There is no nausea or vomiting. There may be photophobia or phonophobia (but not both).

Diagnostic Criteria (ICHD-3):

  • At least 10 episodes. Duration from 30 min to 7 days.
  • At least 2 of: bilateral, oppressive, mild-moderate intensity, not aggravated by activity.
  • No nausea or vomiting.
  • There can be photophobia OR phonophobia, not both.

Other Headaches and Secondary Headaches

Less frequent but important to consider. Secondary headaches are a symptom of another pathology.

Cluster Headache

Very rare in pediatrics. Unilateral, periorbital pain, very intense, with ipsilateral autonomic symptoms (tearing, rhinorrhea, ptosis).

Secondary Headaches

They are a symptom of another condition. The causes may be infectious (meningitis, sinusitis), trauma, intracranial hypertension (tumors, hydrocephalus), vascular, etc. The suspicion is based on the warning signs.

Warning Signs (SNOOP4)

The presence of any of these findings requires ruling out a secondary cause and urgently considering neuroimaging tests.

SSystemic: Systemic symptoms (fever, weight loss) or underlying disease (cancer, immunosuppression).
NNeurologic: Focal neurological signs or symptoms (seizures, altered consciousness, papilledema).
OOnset: Sudden, abrupt onset, "the worst headache of my life."
OOlder: Onset at age > 50 years (adapted in pediatrics as pattern change or progressive headache).
PPattern change & Positional: Change in pattern (frequency, intensity), postural headache (worse when lying down/getting up), precipitated by Valsalva.
PPapilloedema: Papilla edema in the fundus.
PProgressive: Headache that progressively worsens over weeks or months.
PPrecipitated by cough/exertion: Precipitated by coughing, sneezing or exercise.

Diagnostic Tests

Most headaches do not require testing. They are requested in the presence of alarm signs or diagnostic doubts.

Neuroimaging (cranial CT or MRI)

MRI is of choice because it does not use radiation and has better resolution. Indicated if there is:

  • Abnormal neurological examination.
  • Signs of intracranial hypertension (papilledema, headache that awakens at night, morning vomiting).
  • Significant change in headache pattern.
  • Headache that does not respond to adequate treatment.
  • Severe post-traumatic headache or loss of consciousness.

Lumbar puncture

Indicated when suspected CNS infection (meningitis, encephalitis) or idiopathic intracranial hypertension. Always perform an imaging test first if there is neurological focality or papilledema.

Therapeutic Approach

Acute Episode Treatment

Administer the drug early, at the beginning of symptoms, for greater effectiveness.

1st Line: NSAIDs

Ibuprofen: 10 mg/kg/dose (max. 600 mg).

Paracetamol: 15 mg/kg/dose (max. 1g).

2nd Line: Triptans (Migraine > 6 years)

Second-line drugs for moderate-severe migraine that does not respond to NSAIDs. Use under medical supervision.

Sumatriptan nasal: >12 years. Dosage of 10-20 mg.

Oral rizatriptan: >6 years and >40kg.

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Preventive and Non-Pharmacological Treatment

Consider whether the headaches are very frequent (>3-4 per month), prolonged, or significantly interfere with the child's life.

Non-Pharmacological Measures

  • Sleep hygiene: Regular hours, sleep enough hours.
  • Feeding: Avoid prolonged fasts, good hydration.
  • Stress management: Relaxation techniques, cognitive-behavioral therapy.
  • Regular physical exercise.
  • Identify and avoid triggers (food, lack of sleep, etc.).

Preventive Pharmacological Treatment

It must be individualized and managed by a specialist.

Common options: Propranolol, Flunarizine, Topiramate, Amitriptyline.

Bibliography and Resources