Headache in children
0Stop — call 999 now
- Fever with neck stiffness, photophobia, drowsiness or rash (meningitis) → 999; antibiotic before transfer only if it does not delay it.
- Sudden severe "worst ever" headache, reduced consciousness, new seizure, acute focal deficit → 999
1Triage by finding
| Finding | Action |
|---|---|
| Raised pressure | Waking or on waking with vomiting, worse lying or coughing, papilloedema → Same-day |
| New neuro sign | Ataxia, nystagmus, squint, head tilt → consider Very urgent 48 h (NG12) |
| HeadSmart | Persistent headache + another symptom, or under 4 → Urgent paediatric |
| Normal exam | Recurrent, well between → migraine or tension-type; diary |
2Screen
- Swollen red eyelid or painful eye movements with sinusitis → Same-day
- Severe hypertension with headache → Same-day paediatrics
- VP shunt with headache or vomiting → Same-day
- Several household members with headaches → carbon monoxide
3Assess
☐ BP with the right cuff ☐ Height, weight, head circumference under 2 ☐ Acuity, eye movements, fundi ☐ Gait, coordination, cranial nerves ☐ Analgesic days per month ☐ Sleep, caffeine, screens, school, mood
Do not: request brain imaging from primary care, or prescribe codeine or aspirin.
4Classify
- Migraine — attacks with nausea, vomiting, light sensitivity; sleeps; normal between.
- Tension-type — pressing, mild to moderate, no vomiting.
- Medication overuse — analgesics on 15 or more days a month.
- Sinusitis · eye strain — nasal symptoms; worse with reading or screens.
- Raised pressure — tumour, hydrocephalus, IIH → same-day.
- Uncertain — diary and review in 2–4 weeks with repeat examination.
5Treat today — doses per BNFC and SPC
- Migraine: ibuprofen or paracetamol early; dark quiet room; no more than 2–3 days a week.
- Aged 12–17: consider a nasal triptan if simple analgesia fails; under 12 → specialist.
- Medication overuse: stop the analgesic; review in 4–8 weeks.
- Sinusitis: self-care, no routine antibiotic. Vision: optometrist.
6Refer routinely
- Paediatrics: frequent migraine needing prophylaxis, atypical aura, uncertainty, chronic daily headache.
- Other: optometrist, CAMHS or school support, dentist.
7Never reassure by
- Headaches that come and go.
- An examination that skipped gait, eyes and fundi.
- A normal examination at a previous visit.
- "Probably migraine" in a child under 4.
- Vomiting labelled as a stomach bug when it is on waking.
8Safety-net — say it, then document it
999 “Call 999 for a sudden very severe headache, headache with fever and a stiff neck or a rash that does not fade, if your child is very drowsy or confused, has a fit or new weakness.” Same day “Contact us the same day if headaches wake your child or come on waking with being sick, or there is new double vision, a squint, unsteady walking or a change in behaviour.”
Repeat attendances for the same headache are themselves a flag — re-examine every time.