This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland with a headache.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Neurology, Queensland Children’s Hospital, Brisbane. It has been endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Headaches can be divided into primary disorders (commonly migraines) and secondary disorders (commonly caused by a viral illness, but include serious conditions such as raised intracranial pressure, intracranial haemorrhage or infection). Headache may also be a manifestation of underlying mental health, substance abuse or psychosocial issues. Headaches in children reach a peak at approximately 11-13 years of age with migraine and tension type headaches as the most predominant forms1.
The pain of headache is not associated with the brain, meninges or skull as these structures do not have nociception. Perception of pain arises from blood vessels (intra- & extracranial), cranial and spinal nerves, face, skull and neck muscles, and other skull structures (teeth, sinuses and ears).2
Headaches account for approximately 1% of paediatric ED presentations.2 Primary disorders represent about 40% and secondary disorders 60% of all paediatric headache presentations to ED. Serious underlying disease are found in 7-15% of paediatric headache presentations.3
| Type | Description | Duration | Frequency |
|---|---|---|---|
| Tension headache |
|
30 minutes to 7 days Months/years if chronic | Most common type of headache affecting patients of all ages. |
| Migraine without aura |
| 1- 48 hours | Most common around 15 years of age (onset age 7 years in boys, 11 years in girls). Prevalence of 3% at age 3-7 years, 4-11% at 7-11 years and 8-23% over 11 years.4 |
| Migraine with aura |
An aura (perceptual disturbance that precedes onset of the headache) may consist of:
Generally consistent for an individual. | Auras may occur from a few seconds to an hour before headache onset. | |
| Cluster headache |
| 15 minutes to 3 hours | Rare in children under 12 years of age |
Migraines have a complicated pathophysiology including cranial vasodilation and sensitisation of trigeminovascular pathways. They are classified as simple or complicated based on their clinical presentation.
Complicated migraines include:
Episodes of complicated migraine, especially the initial episode, can be dramatic and will usually prompt presentation to an ED. In this initial presentation, complete evaluation including imaging is warranted (preferably MRI and MR angiogram) to exclude other causes including stroke, mass lesions and intoxication.
The criteria for a paediatric migraine diagnosis as defined by The International Headache Society6 includes at least five attacks of migraine without aura as described in table above, or at least two attacks of a migraine with one or more fully reversible aura symptoms which can include visual, sensory, speech and or language, motor, brainstem or retinal features with at least three of the following features:
| Raised intracranial pressure (mass effect due to tumour/cyst/vascular lesion, cerebral oedema or increase in fluid (CSF/hydrocephalus or blood) or idiopathic intracranial hypertension (see table below) |
|
| Intracranial infection (including meningitis, encephalitis and brain abscess) |
|
| Intracranial haemorrhage |
|
| Trauma |
|
| Ischaemic stroke |
|
| Venous thrombosis |
|
| Other |
|
| Diagnostic Criteria9 Signs and symptoms of raised intracranial pressure
Absence of localising neurological signs (excluding cranial nerve palsies) Normal CSF analysis Elevated opening pressure ≥25cmH2O in non sedated or obese children Normal to small ventricles on neuroimaging and absence of any tumour | Associated Conditions Primary IIH
Secondary IIH Venous Anomalies & Obstruction
Endocrine Disorders
Drugs
Infectious diseases
Other medical conditions
|
The aim of the assessment is to exclude or identify red flags suggestive of serious underlying pathology to guide appropriate investigation (usually imaging) and treatment. Once a primary disorder diagnosis is established, questioning may differentiate migraine from other primary disorder types (refer to Introduction for descriptions of disorder types).
Appropriate management relies on a careful history and thorough examination.
History-taking should include specific questioning on:
Physical examination should include:
Seek senior emergency/paediatric advice as per local practice if red flags are identified.
Investigations are not routinely required.
The presence of any red flags should prompt consideration of imaging and discussion with senior medical staff. Blood tests may be helpful if considering intracranial infection (refer to Meningitis Guideline).
Refer to flowchart [PDF 555.12 KB] for a summary of the emergency management and medications for children presenting with a headache:
Seek senior emergency/paediatric advice as per local practice if red flags suggestive of serious underlying pathology are identified on assessment.
Opiates are not recommended in acute primary headache.
Simple analgesia is the recommended initial treatment for all primary headache disorders. Consider Ondansetron in a child with vomiting as part of the end points of headache reduction, nausea and vomiting reduction7.
| Paracetamol (Oral) | 15 mg/kg to maximum of 1 g every four hours, maximum four doses in 24 hours |
| Ibuprofen (Oral) | 10 mg/kg to maximum of 400 mg every six to eight hours, maximum three doses in 24 hours |
| Dose | Given orally or sublingually at a dose of 0.15 mg/kg (maximum 8 mg). Tablets and wafers are available in 4 mg and 8 mg doses. Recommended doses are as follows:
|
| Considerations | Ondansetron prolongs the QT interval in a dose – dependent manner. Exercise caution in children who have or may develop prolongation of QTc (such as those with electrolyte disturbances, heart failure or on medications that may lead to a prolongation of the QTc). |
Options for the acute abortive management of migraine include simple analgesia, triptans and dopamine antagonists. Standardised combination therapy of these agents is used in some centres with clinical effect but there are no randomised controlled trials to support efficacy.5 Patients who are given opiates for acute primary headache have longer length of stay in ED and higher rates of return ED visits within seven days when compared to patients given non-opiate medications.6
| Age | Treatment |
|---|---|
| <6 years | Prochlorperazine (Stemetil) (IV) and simple analgesia |
| 6 years and older |
Sumatriptan (intranasal) and simple analgesia Most effective when given early7,10 |
The most investigated combination is Sumatriptan and NSAIDs which has been found to be the most effective7
| Sumatriptan (Intranasal*/PO) |
10-20 mg into 1 nostril or ingested May be repeated once, at least two hours after first dose if symptoms recur (maximum 40 mg in 24 hours) Do not repeat dose during an attack if first dose ineffective. |
| Considerations | Sumitriptan is non LAM for use in children between 6-12 years. Individual patient approval (IPA) would be required in this group. |
| Contraindications |
Ergotamine Children with cardiac disease SSRIs |
*Intranasal sumatriptan is discontinued and supply is likely to be exhausted in 2024.
| Prochlorperazine (Stemetil) (IV) |
0.15 mg/kg (maximum 12.5 mg) as a slow IV push over 2-5 minutes Followed by 20ml/kg sodium chloride 0.9% up to maximum of 1 L administered over one hour if deemed necessary. |
| Or Chlorpromazine (Largactil) (IV) |
0.25 mg/kg in 10-20 mL/kg sodium chloride 0.9% up to maximum of 1 L administered over 30 minutes.
Higher rates of rescue medication, hospitalisation and clinically significant hypotension (despite co-administration of fluid) when compared with prochlorperazine. |
| Or Metoclopramide (Maxolon) (IV) |
0.1-0.15 mg/kg (maximum) 10 mg
Give undiluted over 3 minutes or dilute to 200microgram/mL and infuse over at least 15 minutes. |
| Side effects of dopamine antagonists | Extrapyramidal symptoms such as akathisia and dystonic reactions (see below) |
Acute dystonia is a sustained or brief muscle contraction resulting in twisting movements or abnormal postures. Dystonia can be focal or generalised. It generally develops within minutes to days and affects the face, neck and trunk. Oculogyric crisis, laryngeal spasm and opisthotonus can occur.
Patients and/or caregivers should be specifically counselled about the potential for delayed onset of extrapyramidal symptoms following discharge. While rare, they warrant representation to ED for symptomatic treatment.
| BenzAtropine (IV/IM) |
0.02 mg/kg (to maximum adult dose of 1 mg) in children aged more than three years. Give undiluted. IM route preferred. If IV route is necessary, give undiluted by rapid injection over at least 1 minute. May repeat in 15 minutes. |
Akathisia is an abnormal, uncomfortable sensation of restlessness combined with an urge to move about. On movement, the patient experiences some degree of relief.
| Diazepam (Oral) | 0.04 – 0.2 mg/kg (to maximum adult dose of 2-10 mg) every eight to twelve hours. |
Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.
| Includes child with: | |
|---|---|
|
| Reason for contact | Who to contact |
|---|---|
| Advice (including management, disposition or follow-up) |
Options:
|
| Referral | First point of call is the onsite/local paediatric service |
| Do I need a critical transfer? |
|
| Request a non-critical inter-hospital transfer |
|
| Non-critical transfer forms |
|
Consider discharge for children with a primary headache disorder who have responded to treatment.
Parents/caregivers of a child who has suffered a migraine should receive education on how to manage future migraines (see Headaches and Migraines fact sheet), as well as specific information around extra pyramidal reactions if given Promethazine, Chlorpromazine or Metoclopramide.
If symptoms of primary headache recur, patients should see their GP to consider specialist referral.
Admission to an inpatient service is recommended for a child with a primary headache disorder who fails to respond to treatment. In such cases, alternative diagnoses should be considered.
Children with suspected serious underlying pathology may require admission to an inpatient service, depending on the outcome of investigations.