Skip to main content Accessibility help
Hostname: page-component-848d4c4894-2pzkn Total loading time: 0 Render date: 2024-05-21T07:31:27.128Z Has data issue: false hasContentIssue false

11 - Approach to the Pediatric Patient with Headache in the Emergency Department

Published online by Cambridge University Press:  09 October 2017

Serena L. Orr
Children’s Hospital of Eastern Ontario, Ottawa
Benjamin W. Friedman
Albert Einstein College of Medicine, New York
David W. Dodick
Mayo Clinic, Phoenix, AZ
Get access



Headache is a common presentation in the pediatric emergency department (ED). The majority of pediatric patients presenting to the ED with headache will have a non-life-threatening cause. In order to determine the etiology of the headache, the clinician must take a diligent history and carry out a focused physical exam. Investigations may be required to narrow the differential diagnosis, though in many cases neuroimaging is not required in the acute setting. Headache management will depend on etiology. Although many of the headaches in the pediatric ED are primary headaches, the evidence on how to treat these headaches is limited.

In this chapter, the epidemiology of headache in the pediatric ED will be reviewed. Both detailed and screening approaches to the history and physical exam will be provided. An approach to diagnostic tests and treatment of the primary headaches will be given, incorporating evidence-based recommendations where possible.

Emergency Headache
Diagnosis and Management
, pp. 110 - 124
Publisher: Cambridge University Press
Print publication year: 2017

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1.Abu-Arafeh, I, Razak, S, Sivaraman, B, Graham, C. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Dev Med Child Neurol. 2010;52(12):1088–97.Google Scholar
2.Kan, L, Nagelberg, J, Maytal, J. Headaches in a pediatric emergency department: etiology, imaging, and treatment. Headache. 2000;40(1):25–9.CrossRefGoogle Scholar
3.Burton, LJ, Quinn, B, Pratt-Cheney, JL, Pourani, M. Headache etiology in a pediatric emergency department. Pediatr Emerg Care. 1997;13(1):14.Google Scholar
4.Hsiao, H-J, Huang, J-L, Hsia, S-H, et al. Headache in the pediatric emergency service: a medical center experience. Pediatr Neonatol. 2014;55(3):208–12.Google Scholar
5.Conicella, E, Raucci, U, Vanacore, N, et al. The child with headache in a pediatric emergency department. Headache. 2008;48(7):1005–11.Google Scholar
6.Sheridan, DC, Meckler, GD, Spiro, DM, Koch, TK, Hansen, ML. Diagnostic testing and treatment of pediatric headache in the emergency department. J Pediatr. 2013;163(6):1634–7.Google Scholar
7.Lewis, DW, Qureshi, F. Acute headache in children and adolescents presenting to the emergency department. Headache. 2000;40(3):200–3.Google Scholar
8.Scagni, P, Pagliero, R. Headache in an Italian pediatric emergency department. J Headache Pain. 2008;9(2):83–7.Google Scholar
9.Lee, TT, Uribe, J, Ragheb, J, Morrison, G, Jagid, JR. Unique clinical presentation of pediatric shunt malfunction. Pediatr Neurosurg. 1999;30(3):122–6.Google Scholar
10.Kedia, S, Ginde, A, Grubenhoff, J, et al. Monthly variation of United States pediatric headache emergency department visits. Cephalalgia. 2014;34(6):473–8.Google Scholar
11.Caperell, K, Pitetti, R. Seasonal variation of presentation for headache in a pediatric emergency department. Pediatr Emerg Care. 2014;30(3):174–6.CrossRefGoogle Scholar
12.Soriani, S, Fiumana, E, Manfredini, R, et al. Circadian and seasonal variation of migraine attacks in children. Headache. 2006;46(10):1571–4.CrossRefGoogle ScholarPubMed
13.Lanphear, J, Sarnaik, S. Presenting symptoms of pediatric brain tumors diagnosed in the emergency department. Pediatr Emerg Care. 2014;30(2):7780.CrossRefGoogle ScholarPubMed
14.Medina, LS, Kuntz, KM, Pomeroy, S. Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies. Pediatrics. 2001;108(2):255–63.Google Scholar
15.Yock-Corrales, A, Babl, FE, Mosley, IT, Mackay, MT. Can the FAST and ROSIER adult stroke recognition tools be applied to confirmed childhood arterial ischemic stroke? BMC Pediatr. 2011;11(1):93.CrossRefGoogle ScholarPubMed
16.Edgeworth, J, Bullock, P, Bailey, A, Gallagher, A, Crouchman, M. Why are brain tumours still being missed? Arch Dis Child. 1996;74(2):148–51.Google Scholar
17.Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629808.CrossRefGoogle Scholar
18.Pacheva, I, Milanov, I, Ivanov, I, Stefanov, R. Evaluation of diagnostic and prognostic value of clinical characteristics of migraine and tension type headache included in the diagnostic criteria for children and adolescents in International Classification of Headache Disorders: second edition. Int J Clin Pract. 2012;66(12):1168–77.Google Scholar
19.Trottier, ED, Bailey, B, Lucas, N, Lortie, A. Diagnosis of migraine in the pediatric emergency department. Pediatr Neurol. 2013;49(1):40–5.Google Scholar
20.Schievink, WI, Maya, MM, Louy, C, Moser, FG, Sloninsky, L. Spontaneous intracranial hypotension in childhood and adolescence. J Pediatr. 2013;163(2):504–10.CrossRefGoogle ScholarPubMed
21.Heyer, GL, Fedak, EM, LeGros, AL. Symptoms predictive of postural tachycardia syndrome (POTS) in the adolescent headache patient. Headache. 2013;53(6):947–53.Google Scholar
22.Reulecke, BC, Erker, CG, Fiedler, BJ, Niederstadt, T-U, Kurlemann, G. Brain tumors in children: initial symptoms and their influence on the time span between symptom onset and diagnosis. J Child Neurol. 2008;23(2):178–83.Google Scholar
23.Ansell, P, Johnston, T, Simpson, J, et al. Brain tumor signs and symptoms: analysis of primary health care records from the UKCCS. Pediatrics. 2010;125(1):112–19.Google Scholar
24.Wilne, S, Collier, J, Kennedy, C, et al. Presentation of childhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol. 2007;8(8):685–95.Google Scholar
25.Wilne, SH, Ferris, RC, Nathwani, A, Kennedy, CR. The presenting features of brain tumours: a review of 200 cases. Arch Dis Child. 2006;91(6):502–6.Google Scholar
26.Thompson, M, Van den Bruel, A, Verbakel, J, et al. Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care. Health Technol Assess Winch Engl. 2012;16(15):1100. doi:10.3310/hta16150.Google Scholar
27.Michos, AG, Syriopoulou, VP, Hadjichristodoulou, C, et al. Aseptic meningitis in children: analysis of 506 cases. PLoS One. 2007;2(7):e674.Google Scholar
28.Wei, J-H, Wang, H-F. Cardiac cephalalgia: case reports and review. Cephalalgia. 2008;28(8):892–6.Google Scholar
29.Blumenfeld, H. An interactive guide to the neurologic examination. Sinaeur Assoc Publ Inc. 2010. Available at: Scholar
30.Amarilyo, G, Alper, A, Ben-Tov, A, Grisaru-Soen, G. Diagnostic accuracy of clinical symptoms and signs in children with meningitis. Pediatr Emerg Care. 2011;27(3):196–9. doi:10.1097/PEC.0b013e31820d6543.Google Scholar
31.American College of Emergency Physicians. Clinical policy for the initial approach to adolescents and adults presenting to the emergency department with a chief complaint of headache. Ann Emerg Med. 1996;27(6):821–44.Google Scholar
32.Miglioretti, DL, Johnson, E, Williams, A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700–7.Google Scholar
33.Hoffman, KR, Chan, SW, Hughes, AR, Halcrow, SJ. Management of cerebellar tonsillar herniation following lumbar puncture in idiopathic intracranial hypertension. Case Rep Crit Care. 2015;2015:895035.Google Scholar
34.Thompson, EM, Baird, LC, Selden, NR. Results of a North American survey of rapid-sequence MRI utilization to evaluate cerebral ventricles in children. J Neurosurg Pediatr. 2014;13(6):636–40.Google Scholar
35.Dooley, JM, Camfield, PR, O’Neill, M, Vohra, A. The value of CT scans for children with headaches. Can J Neurol Sci. 1990;17(3):309–10.Google Scholar
36.Maytal, J, Bienkowski, RS, Patel, M, Eviatar, L. The value of brain imaging in children with headaches. Pediatrics. 1995;96(3 Pt 1):413–16.Google Scholar
37.Medina, LS, Pinter, JD, Zurakowski, D, et al. Children with headache: clinical predictors of surgical space-occupying lesions and the role of neuroimaging. Radiology. 1997;202(3):81924.CrossRefGoogle ScholarPubMed
38.Packman, B, Packman, E, Doyle, G, et al. Solubilized ibuprofen: evaluation of onset, relief, and safety of a novel formulation in the treatment of episodic tension-type headache. Headache. 2000;40(7):561–7.Google Scholar
39.Brainin, M, Barnes, M, Baron, J-C, et al. Guidance for the preparation of neurological management guidelines by EFNS scientific task forces: revised recommendations 2004. Eur J Neurol. 2004;11(9):577–81. doi:10.1111/j.1468-1331.2004.00867.x.Google Scholar
40.Bendtsen, L, Evers, S, Linde, M, et al. EFNS guideline on the treatment of tension-type headache: report of an EFNS task force. Eur J Neurol. 2010;17(11):1318–25.Google Scholar
41.Weinman, D, Nicastro, O, Akala, O, Friedman, BW. Parenteral treatment of episodic tension-type headache: a systematic review. Headache. 2014;54(2):260–8.Google ScholarPubMed
42.Langer-Gould, AM, Anderson, WE, Armstrong, MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004–11.Google Scholar
43.DeVries, A, Koch, T, Wall, E, et al. Opioid use among adolescent patients treated for headache. J Adolesc Health. 2014;55(1):128–33.Google Scholar
44.Brousseau, DC, Duffy, SJ, Anderson, AC, Linakis, JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004;43(2):256–62.Google Scholar
45.Trottier, ED, Bailey, B, Dauphin-Pierre, S, Gravel, J. Clinical outcomes of children treated with intravenous prochlorperazine for migraine in a pediatric emergency department. J Emerg Med. 2010;39(2):166–73.Google Scholar
46.Sheridan, DC, Spiro, DM, Meckler, GD. Pediatric migraine: abortive management in the emergency department. Headache. 2014;54(2):235–45.Google Scholar
47.Richer, L, Graham, L, Klassen, T, Rowe, B. Emergency department management of acute migraine in children in Canada: a practice variation study. Headache. 2007;47(5):703–10.Google Scholar
48.Leung, S, Bulloch, B, Young, C, Yonker, M, Hostetler, M. Effectiveness of standardized combination therapy for migraine treatment in the pediatric emergency department. Headache. 2013;53(3):491–7.Google Scholar
49.Orr, SL, Aubé, M, Becker, WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2014;35(3):271–84.Google Scholar
50.Evers, S. The efficacy of triptans in childhood and adolescence migraine. Curr Pain Headache Rep. 2013;17(7):342.Google Scholar
51.D’Amico, D, Moschiano, F, Bussone, G. Early treatment of migraine attacks with triptans: a strategy to enhance outcomes and patient satisfaction? Expert Rev Neurother. 2006;6:1087–97.Google Scholar
52.Sheridan, DC, Spiro, DM, Nguyen, T, Koch, TK, Meckler, GD. Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department. Pediatr Emerg Care. 2012;28(12):1293–6.Google Scholar
53.Gertsch, E, Loharuka, S, Wolter-Warmerdam, K, et al. Intravenous magnesium as acute treatment for headaches: a pediatric case series. J Emerg Med. 2014;46(2):308–12.CrossRefGoogle ScholarPubMed
54.Sheridan, D, Sun, B, O’Brien, P, Hansen, M. Intravenous sodium valproate for acute pediatric headache. J Emerg Med. 2015;49(4):541–5.Google Scholar
55.Lambru, G, Matharu, M. Management of trigeminal autonomic cephalalgias in children and adolescents. Curr Pain Headache Rep. 2013;17(4):323.CrossRefGoogle ScholarPubMed
56.Antonaci, F, Alfei, E, Piazza, F, De Cillis, I, Balottin, U. Therapy-resistant cluster headache in childhood: case report and literature review. Cephalalgia. 2010;30(2):233–8.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats