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Researchers Suggest Stepwise Approach for Managing Childhood Headache

Alison Rodriguez
A recent literature review suggests a new clinical pathway for children presenting with headache in the emergency department. 
Headache represents a leading cause for pediatric visits to the emergency department (ED). A recent literature review suggests a new clinical pathway for pediatric patients with headache in an emergency setting, which involves a stepwise approach to avoid missing secondary headaches.

In a systematic review, headaches in children who went to the ED were primary due to benign conditions that were self-limiting or resolved with appropriate pharmacological treatment, according to the authors. The review revealed that there were more frequent causes of non-traumatic headache in the ED, including primitive headaches and benign secondary headache, while potentially life-threatening secondary headaches were less frequent.

“There has been a substantial increase in the incidence of childhood migraine and headache over the last 30 years. This increase is alarming and likely reflects children's lifestyles. Diagnosis and treatment can be challenging due to its varying presentation, etiology, and triggers. Secondary headaches manifest differently in children than in adults and the degree of brain maturation could be the cause of this difference,” explained the authors. “Headache disorders are the main cause of absence from school, affecting negatively school performance, as well as other daily activities.”

It was also noted that the main goal in the emergency department is to prevent potentially life-threatening conditions through immediate medical attention. During this initial assessment, the review found potential red flags for recognizing life-threatening conditions, including abnormal neurological examination, atypical presentation of headaches, recent and progressive severe headache, no family history of migraine, among others.

The researchers suggest that physicians should consider using appropriate diagnostic tests while assessing a child for headache. These tests would include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography, according to the review. Using a stepwise approach will help physicians diagnose patients and avoid missing anything potentially harmful to the patient.

“A stepwise approach to pediatric headaches is essential to avoid missing secondary headaches and to promptly make the correct diagnosis. A complete history is paramount, including features of the headache and its characteristics, family and social history, and risk factors for systemic illness, as well as the symptoms or factors associated with the headache,” concluded the authors. “A detailed physical and neurological examination, with attention to abnormalities that could be associated with a secondary cause of headache, is important for the subsequent diagnostic workup.” 


Raucci U, Vecchia N, Ossella C, et al. Management of childhood headache in the emergency  department: Review of the literature [published online August 23, 2019]. Frontiers in Neurology. doi: 10.3389/fneur.2019.00886.

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