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Key Features

Essentials of Diagnosis

  • Most common causes in children are migraine and tension-type headache

  • Diagnosis is based on a thorough history and physical, excluding secondary causes such as mass or idiopathic intracranial hypertension

  • Warning signs that may require further investigation

    • Headache in a young child

    • New onset and worsening headache

    • Unexplained fever

    • Awakening with headache or vomiting

    • Headache worse with straining or position change

    • Posterior headaches

    • Neurologic deficit

    • Neurocutaneous stigmata

General Considerations

  • Approximately 11% of children and 28% of adolescents experience recurrent headaches

  • Clinician must determine whether the headache is primary or secondary

  • Based on the 2004 International Classification of Headache Disorders-IIR (ICHD-IIR), primary headaches are divided into three major categories

    • Migraine

    • Tension-type

    • Trigeminal autonomic cephalalgia

Clinical Findings

Symptoms and Signs

  • More than 15 headaches per month (migraine or tension-type) is considered chronic, and medication overuse must be excluded

  • Migraine without aura

    • Duration: 2–72 hours

    • Quality: Throbbing/pounding

    • Severity: Moderate to severe

    • Location: Unilateral/bilateral

    • Physical activity: Worsens headache

    • Associated factors: Nausea/vomiting or photophobia or phonophobia

  • Tension-type

    • Duration: 30 minutes to 7 days

    • Quality: Pressure tight band

    • Severity: Mild to moderate

    • Location: Bilateral

    • Physical activity: No effect

    • Associated factors: Photophobia or phonophobia

  • Trigeminal autonomic cephalalgia (or subcategory, cluster headache)

    • Rare

    • Presents as a unilateral severe headache with autonomic dysfunction (watery eye, congestion, facial sweating, miosis, and ptosis)

Differential Diagnosis

  • Secondary causes include broad categories such as

    • Head trauma

    • Infection

    • Vascular, intracranial pressure changes

    • Structural, metabolic, toxic or substance related

    • Hematologic

  • Medications that are commonly associated with medication overuse headache include

    • Aspirin, acetaminophen, NSAIDs

    • Triptans

    • Combination analgesics such as acetaminophen, butalbital, and caffeine

  • Toxins such as lead, carbon monoxide, or organic solvent poisoning cannot be overlooked


Laboratory Findings

  • Not routinely needed in children with recurrent headaches

  • History and examination may prompt basic screening studies for thyroid, anemia, or autoimmune disorders


  • Routine neuroimaging is not indicated unless a combination of red flags are present

  • Imaging can be considered when

    • Historical features suggest recent onset of severe headache

    • There has been a change in headache

    • Features suggest presence of neurologic dysfunction



  • Rest, relaxation, and cold/hot packs

  • Resting in a cool dark room may provide added benefit

  • To prevent headaches, biobehavioral management can be used

    • Sleep hygiene

    • Improved fluid intake; elimination of caffeine

    • Nutritional meals; avoidance of skipping meals

    • Regular exercise and stretching

    • Stress management


  • Simple analgesics

    • Acetaminophen, 15 mg/kg; max dose: 650 mg

    • Ibuprofen, 10 mg/kg; max dose: 800 mg)

    • Use should be limited to 2–3 times per week

  • Migraine-specific medications

    • Almotriptan and rizatriptan are ...

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