Red flag symptoms: Headaches in children

Know when urgent admission is needed and how to take a thorough history.

  • Sudden-onset headache
  • Recent trauma
  • Photophobia
  • Neck stiffness
  • Fever
  • Non-blanching rash
  • Speech disturbance
  • Weakness of arm, face or leg
  • Decreased conscious level
  • Affecting attendance at school
  • Fits
  • Change in behaviour

Headaches in children are a relatively uncommon presentation.

Children will generally present with a parent or other relative and it is important to develop an idea of what both the family member and the child are concerned about.

It may be that the parent or relative is more concerned about the problem than the child, and this may affect your management.

Key questions to ask

  • When did the headaches start? Try to establish a timeline for the headaches. If they are chronic, establish when the first one started, what the patient was doing at the time, or what the relative noticed at the time.
  • How often do the headaches occur and have they become more frequent? Establish the frequency and how long each headache lasts for.
  • Where is the headache? Ask the child to describe it and ask if the pain ever moves around.
  • Does anything make the headache worse or better (for example, sleep)?
  • Are there associated symptoms? Find out if there are any warning symptoms, if vision is affected and if there is vomiting, any weakness of the arm, face or leg, any speech disturbance or change in behaviour or personality. Is there any relationship to food?
  • Is there any family history of migraine? It may be appropriate to ask about the occurrence of any 'funny turns'.
  • How much analgesia is used?
  • Have the headaches been reported at school? If so, is this affecting the child's ability to perform at school? Is it affecting attendance at school, college or any work if the child is older? Are there any concerns at school? Have the headaches coincided with any examinations?
  • How is everything at home? You may choose to see the child alone. Abuse can manifest as physical symptoms, so be alert to this and note if there is anything significant. For older female children, check if they are taking any contraception.
  • Were there any concerns at the child's birth and is their immunisation schedule completely up to date?
  • For an acute-onset headache, ask when it started. Is the child unwell? Is there any associated fever, photophobia, vomiting, neck stiffness or rash? Has there been any recent trauma? If so, is there any reported discharge from the ear or nose? Has there been any decrease in conscious level? It may be important to know if the child has any leg pain. Is there any other associated viral symptom, such as sore throat, cough or cold-like symptoms? Is there any facial pain?

Examination

The type of examination depends on whether the headaches are acute or chronic in presentation.

With any child, observation in the first few seconds will provide a lot of information, such as if the child is interactive, floppy or irritable. An acute-onset headache will require assessment of conscious level, temperature, capillary refill time and ability to tolerate light.

You may wish to check for a petechial rash, if relevant, or signs of any obvious trauma. Check for any obvious otorrhoea or rhinorrhoea.

Check pulse rate, warmth of peripheries, facial tenderness and any meningism, as required.

If the headache is chronic, assess the gait and power in the arms.

Examine the pupils for any discrepancy in reaction to light and accommodation. Examine the fundi, looking for papilloedema.

Possible causes
  • Acute headache
  • Meningitis
  • Sinusitis
  • URTI
  • Trauma
  • Migraine
  • Chronic headache
  • Migraine
  • Tension
  • Analgesia overuse
  • Space-occupying lesion
  • Temporomandibular joint disorder
  • Iatrogenic
  • Psychological

Investigations

Investigations depend on the acuteness of the presentation, history and examination, although you may wish to consider the use of a headache diary, obtaining further history, or prescribing treatment for migraine if this seems a likely diagnosis.

Referral

If the child is unwell, admit as an emergency if meningitis is suspected. If there has been a head injury and red flags are present, admit as an emergency.

If the headache is chronic, consider referral to paediatrics if there is significant parental concern or lack of response to early treatment. If you suspect a psychological cause, a child and adolescent mental health team might be more appropriate.

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  • Dr Singh is a GP in Northumberland

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