Headache in Children

Neurology
Written By Maladywise

Red flags

  • First or worst headache

  • Recurrrent severe over weeks

  • Increasing frequency or worsening usual headache

  • Mainly from sleep in first thing in the morning

  • Mainly when lying or bending and coughing

  • Vomitting from sleep or before getting up

  • Confusion, impaired consciousness, altered personality

  • Focal motor weakness, diplopia

  • Fevers, rigors, seizures

History

  • Onset, duration, type, frequency

  • Warning symptoms, associated symptoms, nausea, vomiting, pain, severity, localisation

  • Medication and self management

  • Family history

  • Medical history

  • Mental health

Tools

HEEADSSS

  • Home

  • Education and Employment

  • Exercise and Eating

  • Activities and Peer relationsip

  • Drugs, cigarette and alcohol

  • Sexuality

  • Suicide and depression

  • Safety and spirituality

Exam

  • BP, HR, Temp, growth

  • Neuro exam

  • Eye exam for pain, squint, reflexes, papilloedema

  • ENT and sinuses

  • Teeth for caries

  • Skin for neurocutaneous stgmata

Investigate

  • Bloods if indicated - Glucose, TFT, Anaemia, Rheumatology

  • Imaging if indicated - Suspicious, severe, secondary, focal signs, trauma

Diagnosis

  • Intermittent headache 1 to 2 times a month, possibly with nausea and vomitting

  • Not every day

  • Family history in 70%

  • In young children often behavioural change

  • Throbbing or pulsatile in nature is common

  • Aura in 25%

  • Location bilateral and frontal more common in kids but can be anywhere

  • May have clear trigger

  • Sleepwalking, motion sickness, mouth ulcers and “growing pains” all common in children with migraine

Management

  • Consider medication overuse

  • Address any emotional mechanisms that provoke stress

  • Maintain a sound daily routine including regular meals, sufficient fluid intake, physical exercise and sleep

  • Many possible migraine triggers have been suggested, including hormonal, emotional, physical, dietary, environmental and medicinal factors. These triggers are very individual, and a headache diary can help to determine if there is a consistent trigger.

Acute Migraine

  • Paracetamol 15 mg/kg (up to 1000 mg) orally. Wait 4 to 6 hours before repeating the dose if needed (maximum dose 60 mg/kg [up to 4000 mg] in 24 hours).

  • Ibuprofen 5 to 10 mg/kg (up to 400 mg) orally. Wait 4 to 6 hours before repeating the dose if needed (maximum dose 30 mg/kg [up to 2400 mg] in 24 hours).

  • Trial going to sleep in a dark room.

  • Cold packs over the forehead or back of the skull (targeting the supraorbital and greater occipital nerves).

  • Hot packs over the neck and shoulders (targeting the innervation of the scalp).

  • Neck stretches and self-mobilisation.

  • Sumatriptan (Imigran) 10 to 20 mg intranasally. Wait at least 2 hours before repeating the dose if needed (no more than 2 doses in 24 hours). Patients may experience nasal stinging. 1

  • Rizatriptan (Maxalt) (child 20 to 39 kg: 5 mg; child 40 kg or more: 10 mg) orally (disintegrating tablet placed on tongue to dissolve). Wait at least 2 hours before repeating the dose if needed (no more than 2 doses in 24 hours).

Migraine Prophylaxis

Consider prophylaxis if headaches are:

  • Frequent and disabling enough to justify taking regular medication i.e. more than 3 to 4 migraine a month.

  • In a pattern where they are present on almost all days of a week in more than 2 weeks in a month.

  • Affecting social, school, or daily routine.

Under 10

Pizotifen (e.g. Sandomigran)

  • 0.5 mg oral daily at night, gradually increase to 1.5 mg daily in divided doses. Maximum single dose at night, 1 mg.

  • Commonly used to prevent migraines in children.

  • Adverse effects include sedation and increased appetite.

See also NPS Medicine Wise – Sandomigran

Cyproheptadine hydrochloride (e.g. Periactin)

4 mg daily, can increase to 8 mg nocte.

Ensure adequate monitoring for adverse effects, e.g. sedation, paradoxical stimulation in children (e.g. agitation, hallucinations), increased appetite, weight gain.

See also NPS MedicineWise – Periactin

Over 10

Beta-blockers

  • Propranolol – prevention of migraine:

    • Aged 2 to 12 years, oral, initially 0.2 to 0.5 mg/kg 2 to 3 times daily; usual dose 10 to 20 mg 2 or 3 times daily (maximum 4 mg/kg daily).

    • Aged 12 to 18 years, oral, initially 20 to 40 mg twice daily; maintenance dose usually 60 to 80 mg daily in divided doses.

  • Taper dose when stopping treatment to avoid rebound symptoms.

  • Contraindicated in patients with asthma.

Amitriptyline (Endep)

  • Useful for both migraines and chronic daily headache.

  • Aged 2 to 18 years, oral, initially 0.1 to 0.25 mg/kg (maximum 10 mg) at night; gradually increase dose over at least 2 to 3 weeks according to response, up to 1 mg/kg (maximum 75 mg) at night. Consider rounding dose to the nearest 5 mg.

  • Generally 10 to 25 mg daily is sufficient. Specialists may prescribe higher doses but adverse effects often limit the dose.

  • Taper dose when stopping to avoid withdrawal symptoms.

  • Be aware of the potential for anticholinergic adverse effects such as constipation

  • See also NPS Medicine Wise - Endep

Reference:

Headache Clinical Guidelines - RCH

Headache in Children - HNE [Needs Log In]

Maladywise https://www.maladywise.org
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