Diagnosis and Management of Headaches in Children

Diagnostic Approach

The American Academy of Neurology recommends that a detailed clinical history is essential for the diagnosis of headaches in children, including age of onset, duration of episodes, frequency, characteristics of pain, aggravating and relieving factors, and accompanying symptoms 1, 2
The American Academy of Neurology suggests that family history of migraine is crucial, as migraine has a strong genetic component and is frequently positive in pediatric patients 3
The International Headache Society recommends that headache diaries are useful diagnostic tools that also allow for reevaluation of the diagnosis when necessary 4

The International Headache Society proposes that the diagnosis of migraine without aura requires at least 5 attacks, with each attack lasting 4-72 hours, and at least 2 of the following characteristics: unilateral location, pulsating quality, moderate or severe intensity, and aggravation by routine physical activity 2, 4
The American Academy of Neurology recommends that the diagnosis of migraine with aura requires the presence of recurrent visual and/or hemisensory symptoms of short duration 3, 4

The American College of Radiology suggests that neuroimaging is not indicated for children with normal neurological examination and no red flags, as the diagnostic yield is less than 1% for clinically significant findings 6, 5
The American College of Radiology recommends that MRI without contrast is the preferred study for non-emergent evaluation, with higher sensitivity for tumors, stroke, and parenchymal abnormalities 6

The American Academy of Neurology recommends that ibuprofen be used as first-line treatment for acute headache in children and adolescents 1, 2, 3
The American Academy of Neurology suggests that adolescents may also be considered for sumatriptan/naproxen, zolmitriptan, sumatriptan, rizatriptan, or almotriptan 2

The American Academy of Neurology recommends that preventive treatment be considered for children and adolescents with frequent or disabling headaches, or with overuse of acute medication 1, 2
The American Academy of Neurology suggests that amitriptiline combined with cognitive-behavioral therapy, topiramate, or propranolol may be effective for preventive treatment 2

The American Academy of Neurology recommends that patients and families be educated on lifestyle factors, migraine triggers, and avoiding overuse of acute medication 1, 2, 3

The American Academy of Neurology suggests that headache calendars be used to evaluate effectiveness and adverse events 3
The American Academy of Neurology recommends that when results are suboptimal, the diagnosis, treatment strategy, dosage, and adherence be reviewed 3