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This guidance refers to children and young people up to 16 th birthday, or 18th birthday if the young person prefers to be seen in a paediatric setting.
Headache is one of the commonest problems seen in children, and is nearly always primary (idiopathic) in origin. Headaches caused by brain tumours are very uncommon (0.3% of children with headaches have a brain tumour, and 0.03% of children with headaches and no red flags have a tumour) although this is the perennial concern of doctors and parents alike. This guidance helps clinicians to:
Management of secondary headaches.
Nearly all brain tumours and other secondary headaches can be identified on the basis of the history and examination alone.
Determine whether the patient gets more than one type of headache, and for each type establish the following seven features of a typical headache attack
Determine whether red flags are present – see below
Establish a drug history including frequency of analgesic / triptan use. More than 2 doses of analgesic use per week carry a risk of medication overuse headache
Determine the headache pattern. Generally, intermittent headaches (however frequent) with complete recovery in-between indicate primary headache. Progressive headache with other new symptoms are more suggestive (but not diagnostic of) a secondary cause.
A diary can help to identify triggers for headaches.
Headache which:
Where red flags are absent, the likelihood of brain tumour being present is 0.03%
See 'diagnosis' for epidemiology of headaches and brain tumours, below.
Tension-type headache | Migraine (with or without aura) | Short, severe headaches | |
Location |
Bilateral |
Unilateral or bilateral, usually frontal |
Unilateral or bilateral, usually temporal |
Quality |
Constant / tightening |
Throbbing or banging |
Sharp, lightning-like |
Intensity |
Mild or moderate |
Moderate or severe |
Moderate or severe |
Effect on activities |
Rarely incapacitates patient |
Usually incapacitating, and worsened by movement Relieved by sleep |
Restlessness or agitation |
Other symptoms |
None
|
Photophobia / phonophobia can be inferred by behaviour Nausea, vomiting, pallor Aura symptoms
|
Idiopathic stabbing headache = none Cluster headache = autonomic features (e.g. ptosis, midriasis, eye watering). These are very rare in childhood |
Duration |
30 minutes – continuous |
2–72 hours |
Idiopathic stabbing headache: 1-3 seconds, Cluster headache / related: longer less than 3 hours |
Frequency & Diagnosis |
Less than 15 days per month = Episodic tension-type headache More than 15 days per month for more than 3 months = Chronic tension-type headache |
Less than 15 days per month = Episodic migraine (with or
without aura)
More than 15 days per month for more than 3 months =Chronic migraine (with or without aura) |
Highly variable = Idiopathic stabbing headache Cluster |
These are threefold:
Please refer to the formulary guidance on management of migraine in children
Where needed, discuss the benefits and risks of prophylactic treatment for migraine with the child / young person, taking into account their parent or carer's views, own preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life.
Co-morbid migraine and tension-type headache are extremely common
The key to successful treatment is explanation of the problem and what the child / young person and family can expect:
Advise the child / young person / parent or carer:
These are uncommon. Seek specialist advice.
Devon Formulary Chapter 4 Central Nervous System – Management of migraine
e-Referral selection:
Migraine Trust – information for young people
My Cleveland Clinic – information for families on a number of childhood / adolescent conditions – look for 'headaches in children and adolescents'
NICE Guidance on Headaches in over 12's (CG150), 2012
NICE Clinical knowledge summary on Medication Overuse
Fifteen minute consultation: headache in children under 5 years of age, McCrea N, Howells R. Arch Dis Child Educ Pract Ed 2013;98: 181–185.
This guideline has been signed off on behalf of NHS Devon.
Publication date: December 2016