Red flag symptoms
- Sudden-onset headache
- Recent trauma
- Neck stiffness
- Non-blanching rash
- Speech disturbance
- Weakness of arm, face or leg
- Decreased consciousness
- Affecting attendance at school
- Change in behaviour
- Change in gait or balance
- Headache associated with vomiting
- Headache worse in morning or with bending forward
Headaches in children are a relatively uncommon presentation. Children will generally present with a parent or other relative/carer 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.
Try and speak to the child where able.
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/carer 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?
- Has there been any reported visual problem, for example difficulty in distance vision? If so, an optician assessment may be necessary.
- 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 consciousness? 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?
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 consciousness, 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.
- Migraine: these tend to be unilateral and throbbing in nature. There may be some warning such as flashing lights or funny smells. They tend to be associated with nausea, vomiting, and photophobia but eased with sleep.
- Analgesia overuse: this is more common in adults but children using regular paracetamol or ibuprofen may develop analgesic overuse headache, which tends to ease as you wean the medication. The pain relief may be being used to control a different sort of headache or pain.
- Space-occupying lesion: headaches worse in morning and with bending forward. It may be associated with vomiting and other focal neurological symptoms.
- Temporomandibular joint disorder. This may be worse on chewing. There may be a history of excessive chewing gum use or grinding. There maybe be an area of tenderness over the TMJ
- Refractive errors
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.
If the child becomes drowsy, floppy, irritable, or develops a severe headache associated with photophobia, neck stiffness and/or non-blanching rash then an A&E admission should be arranged.
Red flags in head injury include reduced consciousness level, being floppy or irritable, severe headache with vomiting, or any clear discharge from the ears or the nose – if these are present, arrange an urgent admission.
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.
- Dr Singh is a GP in Northumberland