Headaches - Sheffield Children's Hospital
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Headaches Reference: 1703 Written by: Judith Gilchrist 2015, revised by Laura Flemons June 2018 Peer reviewer: Judith Gilchrist Approved: June 2018 Review Due: July 2021 Purpose To aid the assessment and management of children presenting to Sheffield Children’s Hospital with headaches. Intended Audience Healthcare professionals working in Sheffield Children’s Hospital Author: Judith Gilchrist / Laura Flemons Review date: July 2021 © SC(NHS)FT 2018. Not for use outside the Trust. Page 1 of 7
CAEC Registration Identifier: 1703 Sheffield Children’s (NHS) Foundation Trust
Headaches
Table of Contents
1. Introduction
2. Intended Audience
3. Guideline Content
a. Assessment
b. Investigations
c. Treatment
4. References
1. Introduction
Headaches are common in children, increasing in frequency from childhood to
adolescence, affecting 80-90% by the age of 15 years. They account for 0.7%-1.3% of
all paediatric emergency department visits. The vast majority of headaches are not
caused by sinister pathology, but clearly our aim is to identify those with potential
serious causes as well as diagnosing and treating those with benign causes. These
guidelines have been developed to try and help you with this. Please also refer to SCH
ED Guidelines Handbook.
Headaches are classified into primary (e.g. migraine, tension, cluster headaches) and
secondary (headache being a symptom caused by an underlying intracranial or
medical condition).
Headaches are also classified according to time scale:
1) Acute; 1st presentation of primary headache or if severe, serious intracranial pathology
e.g. Sub arachnoid haemorrhage (SAH)
2) Acute recurrent; usually seen with primary headaches
3) Chronic and progressive; suggesting progressive intracranial pathology
4) Chronic non-progressive; usually due to chronic primary or chronic secondary causes.
2. Intended Audience
Healthcare professionals working in Sheffield Children’s Hospital
Author: Judith Gilchrist / Laura Flemons Review date: July 2021
© SC(NHS)FT 2018. Not for use outside the Trust. Page 2 of 7CAEC Registration Identifier: 1703 Sheffield Children’s (NHS) Foundation Trust
Headaches
3. Guideline Content
A. ASSESSMENT
I. History
• All children need a detailed history, including headache onset, duration, severity,
progression over time, exacerbating factors and associated symptoms
(see table in section C for characteristics of headache types).
• Ask about frequency and effect of analgesia.
• A headache diary may be helpful. (minimum 8 weeks)
• Personal history of previous CNS irradiation or head injury.
• Family history of migraines, headaches, brain tumour, leukaemia, sarcoma or early
onset breast cancer.
• Personal or FH of Neurofibromatosis or Tuberous sclerosis and other familial
genetic syndromes.
Red Flags: Symptoms
Very severe with acute onset (thunderclap headache)
Persistent (> 4 weeks) headaches that wake a child from sleep
Persistent (>4 weeks) headaches that occur on waking
Persistent (>4 weeks) headaches at any time in a child younger than 4 years
Confusion or disorientation and a headache
Vomiting and / or nausea on awakening for > 2 weeks
Visual abnormality persisting > 2 weeks
Motor abnormality (even if resolved)
Regression in motor skills, Focal motor weakness, Abnormal gait and / or co-
ordination (unless local cause), Bells palsy with no improvement within 4 weeks,
Swallowing difficulties (unless local cause)
Any combination of growth failure, delayed / arrested puberty and polyuria /
polydipsia
Behavioural change
II. Examination
Examination should include a full general examination (including vital signs). Look
carefully at the head and neck region looking for local causes. Look for peripheral
stigmata. Clearly a detailed neurological examination is essential, including head
circumference in infants. Remember the importance of detailed visual assessment. If
unable or difficult consider referral to ophthalmology.
Author: Judith Gilchrist / Laura Flemons Review date: July 2021
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Headaches
Red Flags: Signs
Reduced GCS
Focal motor weakness
Abnormal gait and / or co-ordination (unless local cause)
Bells palsy with no improvement within 4 weeks
Papilloedema or optic atrophy
New onset nystagmus
Reduction in acuity not due to refractive error
Visual field reduction
Proptosis
New onset paralytic squint
III. Differential Diagnosis
Common causes Rarer causes
Acute headache Systemic illness with fever Subarachnoid
haemorrhage
Local ENT causes
Arteriovenous
Meningitis
malformation bleed
Trauma
Venous thrombosis
Chronic headache Migraine Raised Intracranial
pressure
Tension headaches
Cluster headaches
Poor fluid intake
Benign intracranial
Trauma
hypertension
Carbon monoxide
poisoning
Behavioural
B. INVESTIGATIONS
Neuroimaging
• Consider urgent (within 48 hours) neuroimaging if any of the red flag symptoms or
signs are present.
Also consider in the following;
- Headache in immunocompromised
- Headache with suspected or known metastatic malignancy
Author: Judith Gilchrist / Laura Flemons Review date: July 2021
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Headaches
- Suspected ventriculoperitoneal shunt infection / malfunction
• Investigation of choice is usually non-contrast CT as this is quick and easy. A
contrast CT / MRI may be needed depending on differential diagnosis and following
discussion with a radiologist.
• Neuroimaging for headaches with no red flag symptoms is usually not needed.
However please discuss non urgent neuroimaging with radiologist +/- neurologist if
being considered.
Lumbar Puncture
To be performed in all cases of suspected meningitis. Be aware of contraindications
(see below). May be appropriate to perform neuroimaging first. Remember to check
opening pressures.
Relative contra-Indications for LP; clinically unwell / unstable, prolonged / focal seizure,
focal neurological signs, low GCS, suspected raised ICP (unless BIH), bleeding
disorder.
Other Tests (to consider, depending on differential diagnosis)
Bloods – FBC / coagulation / U&E / LFT / CRP / bone profile / cultures / capillary gas
(look at CO, but don’t be reassured if normal, if possibility get home boilers checked).
C. TREATMENTS
Clearly treatment will depend on the cause. Describing the management of all causes
is beyond the scope of this guideline. Please consult medical literature / relevant
specialities for further advice. This guideline will focus on the management of primary
headaches mainly.
General management
Explanation of likely diagnosis and reassurance that no evidence of other pathology
Recognise the impact the headache has on the patient and their family/carers
Discuss management options including:
o Non pharmacological; good sleep habits & routine, good fluid intake, regular
meals, eliminate precipitants/trial of migraine elimination diet (avoiding
sugary snacks, chocolate, cheese, baked beans, tomatoes, citrus fruits, fizzy
drinks, caffeine, alcohol), regular exercise, eliminate/manage stressors
o Pharmacological
Provide information about headache disorders and support organisations eg The
Migraine Trust website
Explain the risk of medication overuse headaches
Author: Judith Gilchrist / Laura Flemons Review date: July 2021
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Headaches
Specific management
Type of Characteristics Management
headache
Migraine At least 5 attacks of headache that: Non pharmacological:
without aura Last 1 – 72hrs Explanation and reassurance
At least 2 of; unilateral, pulsing quality, Eliminate precipitants
moderate –n severe intensity, aggravated Lifestyle changes/behavioural management
by routine physical exertion
At least 1 of; nausea or vomiting, Pharmacological:
photophobia, photophonia Treat symptoms;
Not attributable to another disorder Simple analgesia
Nasal triptans if > 12yrs
Migraine with At least 2 attacks of headache that: Consider antiemetics
aura Have an aura with at least 1 of; fully
reversible visual symptoms, fully Prophylaxis (if > 2 episodes/month);
reversible sensory symptoms, fully Propanolol or topiramate (counsel girls
reversible dysphasic speech disturbance about the risk of fetal malformations/impact
Have at least 2 of; homonymous visual on hormonal contraceptives).
symptoms or unilateral sensory Consider using amitryptilline.
symptoms, at least 1 aura symptom
developing gradually over 5 mins, each
symptom lasting 5-60mins Review the need for continuing prophylaxis
Not attributable to another disorder 6 months after starting
Tension Band like sensation around the head Avoid/remove stressor
headache Often involve neck and shoulders Simple analgesia
Continuous and progressive throughout
day
Can last for days
May be temporarily relieved by sleep
Often associated with a stressful event
st
Cluster Stabbing severe headache around the Refer for assessment at 1 episode
headache orbit Oxygen +/- nasal triptans for acute
Last 15 – 180 minutes treatment
Occur 1-10 times/day Simple analgesia usually does not work
Autonomic features often present Require neurology input for decisions
(lacrimation, conjunctival injection, nasal regarding prophylaxis
congestion, ptosis, eye lid oedema)
Medication Consider if taking the following for > 3 months: Stop all medication abruptly for 1 month
overuse Triptans/opioids, ergots or combination with close follow-up and support
analgesics on > 10 days /month Advise symptoms likely to worsen initially
Paracetamol or NSAIDs alone or in Prophylaxis for initial headache disorder as
combination for > 15 days per month necessary
Author: Judith Gilchrist / Laura Flemons Review date: July 2021
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Headaches
4. References
1) BMJ Best Practice: Assessment of acute headache in Children
www.bestpractice.bmj.com/best-ptactice/monograph/825
2) www.headsmart.org.uk; Clinical guideline V2 (2016)
3) NICE Clinical Guideline (CG150); Headaches in over 12s: diagnosis and management
(reviewed November 2016)
4) www.migrainetrust.org
Author: Judith Gilchrist / Laura Flemons Review date: July 2021
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