🧠 Chapter 28: Headaches in Children

Nelson's Pediatric Symptom-Based Diagnosis | Primary vs Secondary headache · Migraine · Tension-type · TACs · Red flags · Neuroimaging criteria

🔍 Headaches in Children: Key Concepts

🔹 Primary vs Secondary
Primary: Migraine, tension-type, trigeminal autonomic cephalgias (TACs). Benign. Secondary: due to infection, tumor, hemorrhage, vascular disorders → red flags.
⚡ Migraine headache
Unilateral/bilateral, throbbing, moderate-severe, aggravated by activity. Duration 2-72h (children shorter). Aura in 15-30% (visual, sensory). Nausea/photophobia/phonophobia.
🧘 Tension-type headache
Bilateral, pressing/tightening, mild-moderate, not aggravated by routine activity. No nausea/vomiting. Photophobia or phonophobia but not both.
🚩 Red flags (SNOOP10)
Thunderclap, awakening from sleep, morning vomiting, focal deficits, papilledema, positional aggravation, new headache with underlying illness.
📋 Neuroimaging indications
Abnormal neuro exam, headache waking child, confusion, recent trauma, age <3y, change in pattern, seizures, thunderclap.
💊 Acute & preventive
Acute migraine: ibuprofen, acetaminophen, triptans (adolescents). Prevention: amitriptyline, propranolol, topiramate, lifestyle triggers.

💡 Key takeaway: Most pediatric headaches are primary (benign), but always screen for secondary causes using red flags. Thunderclap headache requires immediate neuroimaging for subarachnoid hemorrhage. Migraine in children often bilateral, shorter duration, and responds well to early treatment.

🩺 Clinical Approach to Pediatric Headache: Step-by-Step

🔹 Step 1: Recognize emergent red flags (SNOOP10)
• Thunderclap headache (worst ever) → subarachnoid hemorrhage, RCVS, dissection.
• Headache waking child from sleep, morning vomiting → ↑ICP.
• Focal neurologic deficits, papilledema, confusion, seizures.
• Positional variation (worse recumbent) → mass or pseudotumor.
• New headache in immunocompromised or with malignancy.
🔹 Step 2: Characterize primary headache phenotype
• Migraine: moderate-severe, throbbing, unilateral (or bilateral in young), nausea/vomiting, photophobia/phonophobia, relieved by sleep.
• Tension-type: mild-moderate, bilateral band-like, no nausea, ≤1 of photophobia/phonophobia.
• Cluster: severe orbital pain, ipsilateral autonomic signs (tearing, rhinorrhea), restlessness.
• Chronic daily headache (>15 days/month) → medication overuse or chronic migraine.
🔹 Step 3: Targeted history & diary
• Timing, triggers (foods, sleep deprivation, stress), response to medication.
• Headache diary to track frequency, disability, response.
• Family history of migraine, red flags for secondary etiology.
🔹 Step 4: Physical exam & indications for neuroimaging
• Complete neurologic exam + fundoscopy for papilledema.
• Indications for MRI/CT: abnormal neurologic exam, morning headache/emesis, <3 years, change in pattern, seizures, thunderclap, VP shunt.
🔹 Step 5: Management & follow-up
• Acute migraine: NSAIDs + triptans (≥12y) if severe, plus antiemetics.
• Preventive therapy if ≥4 migraines/month, disabling: amitriptyline, propranolol, topiramate.
• Treat underlying secondary cause. Reassess if headache pattern changes.