Management of Headache and Vomiting in Children

Initial Assessment and Red Flags

The American College of Radiology recommends assessing for red flag features such as altered mental status or decreased level of consciousness, severe or "worst headache of life" presentation, and headache that awakens from sleep or worsens with Valsalva maneuver, which indicate serious pathology in children 1, 2
The presence of focal neurological signs, such as ataxia, hemiparesis, papilledema, or cranial nerve palsies, requires immediate evaluation for life-threatening causes 1
Recent head trauma is a significant red flag that necessitates urgent intervention 3

The American College of Radiology suggests performing a complete neurological examination, including vital signs, fundoscopic examination, nuchal rigidity assessment, and evaluation for focal neurological deficits, to identify potential life-threatening causes 4, 5
Neuroimaging is not routinely recommended for children with primary headache and normal neurological examination, but MRI brain without contrast is the preferred initial imaging modality when indicated 3, 4, 5

The American Academy of Family Physicians recommends supportive care with hydration and simple analgesics, such as ibuprofen, for suspected viral illness or migraine 6, 7, 8
For severe migraine with prominent vomiting, non-oral routes, such as non-oral triptan with antiemetic, may be necessary 6, 7, 9
Avoid opioids and butalbital-containing compounds, as they can lead to medication overuse headache, dependency, and rebound headaches 6, 7, 8, 9

Do not miss meningitis, as any fever with headache, vomiting, and altered mental status requires immediate evaluation 1
Do not overlook occipital headache, as this location is statistically associated with serious underlying disease in children 2
Do not use acetaminophen alone for migraine, as it is ineffective as monotherapy 2, 8
Do not create medication overuse headache by limiting acute treatment to no more than twice weekly 6, 7
Do not order routine neuroimaging, as it is not indicated with normal examination and no red flags 3, 4, 5