Headache in Children Algorithm

1

Safety

Red Flags — Meningitis, Raised Pressure & Brain Tumour

Done

Most childhood headache is migraine, tension-type or part of a viral illness. Every child needs a neurological examination, fundoscopy where possible, a visual check, BP, and growth plotted. For adults see the Headache algorithm.

Fever + headache + neck stiffness, photophobia, drowsiness or rash Suspected bacterial meningitis or meningococcal disease → 999; antibiotic before transfer only if it will not delay it (NICE NG240)

Sudden severe "worst ever" headache Peak within minutes, or with collapse, seizure or reduced consciousness → 999 (haemorrhage, venous sinus thrombosis)

Acute focal neurology or reduced consciousness New weakness, speech or visual loss, confusion, new seizure → 999

Features of raised intracranial pressure Headache waking the child or present on waking with vomiting, worse lying down, coughing or straining; papilloedema; bradycardia with high BP → Same-day paediatric assessment (999 if drowsy)

Newly abnormal cerebellar or other central neurological function Ataxia, clumsiness, nystagmus, new squint, head tilt, loss of skills → consider Very urgent referral (48 h) for suspected brain tumour (NICE NG12); same-day discussion with paediatrics if progressing

Head injury Headache after head injury with vomiting, drowsiness, amnesia or a bleeding risk → A&E per NICE NG232

Orbital or sinus complication Swollen red eyelid, painful or restricted eye movements, reduced vision with sinusitis → Same-day ENT / ophthalmology / paediatrics

Raised BP for age Confirmed with the right cuff size; severe hypertension with headache or visual symptoms → Same-day paediatric assessment

Brain tumours are the commonest solid tumours of childhood and are notoriously slow to diagnose: symptoms are often intermittent and appear in different combinations over time. HeadSmart (RCPCH-endorsed supporting guidance) emphasises that symptoms which resolve and recur do not exclude a tumour. NICE NG12 recommends considering a very urgent referral (appointment within 48 hours) for children and young people with newly abnormal cerebellar or other central neurological function.

2

Diagnose

History — From the Child and the Parent

Done

Pattern

Acute single episode, recurrent episodes with normal health between (migraine), daily or near-daily, or progressive (getting more frequent or severe — a warning pattern)

Timing

On waking or waking the child from sleep; worse lying down, coughing or straining; time of day; school days versus holidays

Character

Site, severity (missing school or play), duration (migraine in children can last 2–72 hours and is often bilateral and frontal), throbbing or pressing

Associated features

Nausea, vomiting (especially morning), photophobia, phonophobia, aura, abdominal pain, dizziness; fever, nasal symptoms

HeadSmart brain tumour symptoms

Persistent or recurrent vomiting; balance, coordination or walking problems; abnormal eye movements, blurred or double vision, new squint; behaviour change or lethargy; fits; abnormal head position; delayed or arrested puberty or slow growth; increasing head circumference in infants; excessive thirst and urination (diabetes insipidus)

Medicines

Analgesic use — days per month (medication overuse); caffeine drinks; new medicines (e.g. isotretinoin, tetracyclines — raised pressure)

Triggers and lifestyle

Sleep, missed meals, dehydration, screen time, exercise, stress, bullying, exams, mood, family conflict

Background

Family history of migraine; head injury; VP shunt (shunt blockage → same-day); recent infection; travel; others at home with headaches (carbon monoxide)

Child's own account

Ask the child to draw or point to the pain; explore worries and safeguarding where relevant

Migraine is common in children and often has prominent nausea, vomiting and abdominal pain; attacks may be shorter than in adults. A short history that is progressing, a headache associated with sleep or posture, and any other HeadSmart symptom should move you towards early specialist assessment. A headache diary over 2–4 weeks clarifies pattern and analgesic use.

3

Diagnose

Examination — Every Child, Every Time

Done

Observations

Temperature, HR, RR; BP with an age-appropriate cuff (compare with centile charts)

Growth

Height and weight on a centile chart; head circumference in under-2s; pubertal stage if relevant

Eyes

Visual acuity (Snellen or age-appropriate chart), eye movements and squint, pupils, visual fields to confrontation, fundoscopy for papilloedema (if not possible, refer to an optometrist or eye service the same day when raised pressure is suspected)

Neurology

Gait (walk, heel–toe, hop), coordination (finger–nose), cranial nerves, tone, power, reflexes, head tilt; meningism if febrile

Local causes

Sinus tenderness, ears, teeth, temporomandibular joint, neck muscles

Skin

Rash (meningococcal), café-au-lait patches (neurofibromatosis), bruising (safeguarding)

A normal neurological and fundoscopic examination is reassuring but does not exclude a tumour — repeat it if symptoms persist. Fundoscopy is hard in young children; community optometrists can examine the fundi and test acuity, and NHS sight tests are free for under-16s.

4

Diagnose

Investigations — Few, Targeted

Done

Headache diary

2–4 weeks: frequency, duration, triggers, analgesic days, school missed

Eye test

Optometrist sight test for blurred vision, eye strain or headache with reading or screens; same-day eye assessment if papilloedema is possible

Urine dipstick

If BP is raised (renal cause)

Bloods

Not routine. FBC if pallor or fatigue; others only by clinical picture

Brain imaging

Not requested from primary care for typical migraine or tension-type headache. Children with red flags or persistent HeadSmart features are assessed and imaged via the paediatric / neuroimaging pathway — do not delay referral to arrange a scan

Carbon monoxide

If several household members have headaches, worse at home: advise appliance checks and seek same-day advice if symptomatic

Imaging children with typical primary headache and a normal examination rarely helps and can find incidental abnormalities that cause anxiety. The decision to scan rests on red flags and HeadSmart features, made with the paediatric team.

5

Diagnose

Differential Diagnosis

Done

Migraine

Recurrent attacks, often bilateral or frontal in children, throbbing, with nausea, vomiting, pallor, light and noise sensitivity; wants to lie down in a dark room and sleeps; normal between attacks; family history common. Variants: abdominal migraine, benign paroxysmal vertigo

Tension-type headache

Pressing, band-like, mild to moderate, no vomiting, carries on with activities; stress, posture, sleep

Viral illness / fever

Headache with fever and a clear source in a well child

Medication-overuse headache

Daily headache with analgesics on 15 or more days a month (10 or more for triptans or combinations) for more than 3 months

Acute sinusitis

Older children: nasal blockage, discharge, facial pain after a cold; sinusitis is an uncommon cause of chronic recurrent headache

Refractive error / eye strain

Frontal ache after reading or screens, eases with rest

Raised intracranial pressure

Brain tumour, hydrocephalus or shunt failure, idiopathic intracranial hypertension (overweight adolescent girls, visual obscurations, pulsatile tinnitus, papilloedema), venous sinus thrombosis

Other

Post-traumatic headache, hypertension, dental or TMJ pain, caffeine withdrawal, sleep disorder, anxiety or depression, carbon monoxide

Use ICHD-3 criteria for migraine without aura in children: at least 5 attacks lasting 2–72 hours, with 2 of unilateral or bilateral location, pulsating, moderate or severe, worse with activity; and nausea/vomiting or photophobia with phonophobia. Idiopathic intracranial hypertension threatens sight and needs same-day assessment when papilloedema is found.

6

Refer

Referral — Urgency

Done

999

Suspected meningitis or meningococcal disease, thunderclap headache, reduced consciousness, new seizure, acute focal deficit

Same-day

Raised intracranial pressure features or papilloedema; suspected shunt malfunction; orbital complication of sinusitis; severe hypertension; progressive neurological signs

Very urgent · 48 h · NICE NG12

Consider for newly abnormal cerebellar or other central neurological function — suspected brain or CNS tumour (local paediatric pathway)

Urgent paediatric

HeadSmart features: persistent headache that wakes the child or is present on waking; persistent headache in a young child (under 4); persistent headache with any other HeadSmart symptom (vomiting, visual, motor, growth, behaviour) — discuss or refer via the local paediatric / neuroimaging pathway

Paediatric (non-urgent)

Frequent migraine needing prophylaxis, diagnostic uncertainty, migraine with atypical aura, chronic daily headache not settling after medication withdrawal

Other routes

Optometrist (vision); CAMHS or school support for anxiety, low mood or bullying; dentist

HeadSmart imaging timeframes are supporting guidance, not NG12 timeframes; the NG12 trigger is the newly abnormal neurological examination. Primary care should not arrange brain imaging independently for every child with persistent headache — discuss with the paediatric team.

7

Treat

Management at This Consultation

Done

Migraine attack

Ibuprofen or paracetamol First-line

Ibuprofen (often more effective) or paracetamol at the start of the attack, dose by age or weight per BNFC; rest in a dark, quiet room. Anti-emetic for marked nausea per BNFC. Analgesia on no more than 2–3 days a week

Migraine, aged 12–17

Consider a nasal triptan

If simple analgesia fails: consider a nasal triptan, with ibuprofen or paracetamol if needed (NICE CG150; sumatriptan nasal spray is licensed from 12 years — check the SPC). Triptans under 12 and any prophylaxis → specialist advice

Tension-type headache

Reassure, simple analgesia

Paracetamol or ibuprofen on limited days; address sleep, hydration, screens, stress and school issues. No opioids

Medication-overuse headache

Stop the overused analgesic

Explain it will get worse before better (usually 1–2 weeks), stop abruptly with support, diary, review in 4–8 weeks; refer if not settling

Acute sinusitis

Self-care; no routine antibiotic

Paracetamol or ibuprofen; most settle within 2–3 weeks (NICE NG79). Antibiotic only if systemically very unwell or high risk; any orbital or neurological sign → same-day

Eye strain · raised BP

Sight test · repeat BP

Optometrist sight test. Raised BP: repeat with the correct cuff; persistent raised BP in a child → paediatric referral (urgency by level and symptoms)

Next steps: see Migraine · Tension-type headache · Sinusitis

NICE CG150 covers young people aged 12 and over; for younger children, ibuprofen and paracetamol are the mainstay, and triptans and prophylaxis are specialist decisions. Aspirin must not be given to children under 16 (Reye's syndrome). Codeine is contraindicated for pain in children under 12 and should be avoided in headache.

8

Lifestyle

Self-Care & Trigger Management

Done

Regular routine Regular sleep and wake times, regular meals (no skipped breakfast), enough fluids.

Caffeine Cut down energy drinks, cola and coffee gradually.

Screens and posture Breaks from screens, good lighting, eye test if reading triggers headache.

Exercise Regular physical activity; maintain a healthy weight (also lowers IIH risk).

Stress and school Talk about worries, bullying, exams; agree a school plan so attacks can be managed in school.

Headache diary Records triggers and medicine days; bring it to review.

Lifestyle regularity reduces attack frequency in many children with migraine and tension-type headache. School absence feeds anxiety; a written plan for school helps.

9

Safety

Follow-Up & Safety-Netting

Done

2–4 weeks

Review the diary, analgesic use and examination (including fundi and gait) for new or persistent headache

Persistent or changing

Re-examine at each visit — a new neurological sign or HeadSmart feature changes the urgency; multiple attendances for the same symptom are themselves a flag

Safety-net 999

Sudden very severe headache, headache with fever and a stiff neck, dislike of light or a rash that does not fade, very drowsy or confused, a fit, new weakness

Safety-net same-day

Headaches waking your child or present on waking with being sick, getting worse quickly, new double vision, squint or blurred vision, unsteady walking or clumsiness, a head tilt, or a change in behaviour

Return

Headaches becoming more frequent, school being missed, or painkillers needed on more than 2–3 days a week

Children with brain tumours often present several times before diagnosis; scheduled review with repeat examination, and specific safety-net advice, reduce delay. Document the neurological and eye examination at each visit.

🧒 Headache in Children

Red Flags — Meningitis, Raised Pressure & Brain Tumour

History — From the Child and the Parent

Examination — Every Child, Every Time

Investigations — Few, Targeted

Differential Diagnosis

Referral — Urgency

Management at This Consultation

Self-Care & Trigger Management

Follow-Up & Safety-Netting