Headache (Paediatric)

Any child presenting with a new or changed headache should be assessed for red or amber flags (listed in the tables below) through history and examination. Examination should include:

Growth (up to date trend of height and weight and OFC if <2 years old)
HR and BP (if correct cuff available)
Neuromotor, cerebellar and cranial nerve examination
Fundoscopy is limited in the GP setting so advise an optician appointment (ideally within 1 week)

If indicated from the history, consider also doing a pubertal status, ENT or MSK neck examination.

Red Flag	Possible Intracranial pathology	Referral
• Wakes through the night with headache or present on waking • Aggravated by increased pressure e.g. sneeze/bending down • Recurrent and/or early morning vomiting • Papilloedema • Infant with sun-setting sign (failure of upward gaze) • Increasing head circumference (crossing 2 centiles in <2y old) • Presence of VP shunt	Raised ICP (intra- cranial pressure)	Urgent same day ED
• Under 4 years of age • Associated neurology e.g. ataxia	Space Occupying Lesion	Urgent same day ED
• Fever (without signs of URTI or other source of infection) • Signs of meningism e.g. photophobia, neck stiffness	Meningitis/Encephalitis	Urgent same day ED
• Headache within 5 days of head injury (that is not helped with simple analgesia)	Traumatic Intracranial Bleed	Urgent same day ED

Amber Flags	Possible secondary cause	Referral
• Stigmata of neurocutaneous syndromes e.g. neurofibromatosis and tuberous sclerosis	Space Occupying Lesion	Urgent Neurology OPC
• Delayed/accelerated puberty • Teenager with a constant headache • Progressing headache	Space occupying lesion	Urgent Medical Paediatric OPC
• Poor growth • High BP	Metabolic / Endocrine / Renal / Other	Medical Paediatrics OPC

Once red and amber flags have been ruled out then the history can focus on distinguishing which primary headache the child is likely presenting with (see the table below for the distinguishing characteristics).

Type of primary headache	Characteristics
Tension-type headache	• Mild – moderate (minimal impact on daily activities) • Bilateral
Migraine	• Moderate – severe (causes child to stop activities) • Bilateral (teenagers may describe it as unilateral) • +/- Aura e.g. visual (flickering lights, spots or lines, partial loss of vision), sensory (paraesthesia / numbness) or speech disturbance • Associated nausea / vomiting, photo / phonophobia • Family history
Cluster headache	• Rare • Severe (agitated and pacing the floor) • Unilateral around the eye • Associated ophthalmic symptoms (red watering eye, swollen / drooping eyelid, constricted pupil) and / or nasal congestion, facial sweating
Medication overuse headache	• Taking paracetamol or NSAIDs ≥15 days of the month for ≥3 months

In most cases of headache, provided growth is good and in the absence of red and amber flags, no further investigation is required.

D.M, A.B, C.H & E.P – 01-06-26

Who can refer:

GPs and Advanced Nurse Practitioners.

Who to refer:

Refer any child displaying red flag symptoms suggestive of intracranial pathology urgently to RHCYP emergency department
Refer any child displaying amber flags suggestive of a secondary cause to Medical Paediatrics / Neurology as above
Refer any child whose headache is not controlled with primary care management to Medical Paediatrics

Who not to refer:

Adolescents aged 16 years or above should be referred to adult services

How to refer:

SCI gateway.

Edinburgh, East & Midlothian: RHCYP > Medical Paediatrics or RHCYP >Neurology

West Lothian: St. John’s Hospital > Paediatrics > LI Basic Sign Referral

The following management advice is for primary headaches in children where red and amber flags have been ruled out and a secondary cause is not suspected.

Print the appropriate PIL for your patient (the PIL includes excellent advice on lifestyle management, using a headache diary and relaxation techniques).

Lifestyle and psychosocial management

Lifestyle habits and psychosocial stressors are important to address as potential triggers or exacerbators of the headaches:

Hydration – ensure drinking the appropriate fluid volume per day for the child’s age Fluid (water and drinks) and hydration – BDA. Avoid sugary, fizzy and caffeinated drinks.
Diet – regular healthy meals (avoid missing meals), avoid artificial flavourings and sweeteners.
Sleep – ensure getting adequate hours for the child’s age, How much sleep do you really need? | Sleep Health Foundation
Screen time – advice is no screen time under 2 years, 1 hour / day from 2 – 5 years, no more than 2 hours / day over 5 years (of ANY screen).
Stress – address any home or school stressors, get support from school / online resources / third sector support / CAMHS if appropriate.
Drugs – ensure you ask about and advise against alcohol, drugs, smoking and vaping in teenagers.
Headache diary – a helpful way for children and families to identify triggers and helpful for secondary care assessment if referred. The-Migraine-Trust-headache-diary.pdf
If medication-overuse headache is suspected:
- Withdraw overused medication gradually over 2-4 weeks
- Advise symptoms likely to get worse in short term (for 1-3 weeks) and can take up to 2 months before clear improvement
If there is a cervicogenic element to the headache consider home neck stretches and referral to paediatric physiotherapy

Acute management

First line is paracetamol and / or ibuprofen. Limit to three days per week to prevent medication overuse headache.
If a migraine is suspected, second line is combination therapy of paracetamol or ibuprofen with a triptan. An anti-emetic such as prochlorperazine can also be considered even in the absence of nausea and vomiting. (see the table below for information on these medication options)

Prophylaxis

For the majority of children, focusing on lifestyle habits, psychosocial needs and acute pain management is likely to be sufficient. However, in the minority of children who continue to have regular headaches impacting their quality of life despite this, prophylaxis should be considered. Prophylactic management can be started in the primary care setting.

There is limited evidence of benefit for prophylaxis treatment in children and this needs to be weighed up against potential harms of side effects. Prophylactic medication should be reviewed after 6 months to consider whether there is ongoing need for continued use.

For migraines in over 12 year olds, Propranolol is first line. If under the age of 12 years, Pizotifen is a reasonable first line prophylaxis.
For chronic tension-type headaches in 12–17 year olds, NICE recommends considering:
- a course of 6–10 sessions of acupuncture (if families are willing to access this privately)
- Cognitive Behavioural Therapy for relaxation techniques. (CBT for headaches is not available under the NHS, however families may consider to access this privately or alternatively you could give resources on relaxation PowerPoint Presentation)

See the table below for information to consider when prescribing Migraine medications.

Medication	Licensing and dosing in BNFc	Key considerations	Side effects*
Sumatriptan	Licensed >12y nasal route. Off-license oral dosing for >6 years.	Zolmitriptan to be considered if >12 years and headache duration is longer.	Dizziness, fatigue, dry mouth, flushing, tingling of skin.
Prochlorperazine	Licensed >12y buccal administration. Not licensed for Migraine indication in <12y.		Fatigue, constipation, dry mouth, dizziness.
Ondansetron	Off-license use.	Small increased risk of cleft palate if taken in 1^st trimester of pregnancy, may be relevant when prescribing in teenage girls.	Constipation, feeling hot.
Propranolol	Licensed.	Increased deaths due to Propranolol overdose. Consider patients mental health before prescribing. Avoid if asthmatic.	Fatigue, bradycardia, dyspnoea, sleep disorders.
Pizotifen	Licensed >5 years.		Fatigue, weight gain, dry mouth.
Amitriptyline	Off-license use.	Anticholinergic syndrome, QT prolongation. Caution if weaning/stopping due to withdrawal.	Dry mouth, constipation, drowsiness.

Nutracuticals

There is some limited evidence for the use of riboflavin, vitamin D, magnesium and melatonin. These can be purchased over-the-counter as a suitable low-risk intervention prior to commencing prophylactic medication or used in conjunction. For advice on suggested doses see this link Neuro_Dietary supplements sheet.pdf

Information for primary care professionals: