Recommendations for Pediatric Headache Practice: Differentiating Primary and Secondary Headache Disorders

Headache affects up to 62% of pediatric patients, with 11-23% of patients experiencing migraine disorder. Proper diagnosis is essential to distinguish between primary and secondary headache disorders and begins with a thorough pediatric interview and physical examination. Managing pediatric headache starts with establishing a thorough, multi-disciplinary approach to achieve optimal care.

This can be achieved through creating a local network of healthcare professionals to aid in differential diagnosis and treatment. It is also important to note that a primary and secondary headache diagnosis are not mutually exclusive, a patient can have both headache etiologies. The following are recommendations for pediatric headache practice management to aid in diagnostic proficiency.

1. Comprehensive Interview

• Headache frequency, severity, location
• OR you can use PQRST – P (provocation, palliation), Q (Quality), R (region, radiation), S (severity, stops), T (timing, treatment)
• Light or sound sensitivity
• Nausea or vomiting
• Pain with exercise, cough, bending (pressure induced)
• Pain wakes one from sleep/sleep disturbances/sleep apnea
• Pulsitile tinnitus
• Neck or back pain
• Mood/social changes/concern for abuse or neglect
• Vision changes/eye pain
• Tooth ache/jaw pain/dental problems

2. Focused Physical Examination

• Vitals (BP, pulse, BMI)
• Neurologic examination
• Ophthalmologic examination – essential to rule out papilledema
• Jaw/TMJ area
• Airway – tonsil hypertrophy
• Shoulders and neck/range of motion
• Gait and balance
• Skin exam – neurocutaneous syndromes
• Social/emotional communication

3. Disability Scales – to assess level of impairment

• PedsMIDAS – Headache
• HIT-6 - Headache
• GAD-6 - Anxiety
• PHQ-9 – Depression

4. Red Flags in pediatric headache (SNOOPPPY) – evaluate need for neuroimaging

• Systemic symptoms of illness: “illness: fever, altered level of consciousness, anticoagulation, pregnancy, cancer, HIV infection (especially concerning in new HIV diagnosis, poor control/compliance or associated fever)”
• Neurologic signs: papilledema, asymmetric cranial nerve function, asymmetric motor function, abnormal cerebellar function, new seizure, focal findings on exam".
• Onset: “Onset recently or suddenly (thunderclap headache)”
• Occipital: “occipital localization of pain”
• Pattern: "precipitated by valsalva”, “positional”, “progressive”, and “parents - lack of family history”
• Years: “age<6”

5. Potential Further Evaluations- to rule out secondary headaches if indicated

• Neuroimaging – MRI, MRA, MRV, CT – mass, Chiari Malformation, trauma, high or low pressure headache, congenital anomalies, aneurysm, thrombus (CT is less desirable due to radiation exposure)
• Sleep study – Obstructive Sleep Apnea, parasomnias
• Laboratory studies – metabolic causes(iron/ferritin, vitamin B12, thyroid, CMP, CBC)
• EEG – headache post seizure
• Lumbar Puncture – rule out idiopathic intracranial hypertension, low CSF pressure headache

6. Set Up Trusted Diagnostic and Therapeutic Referral Sources Beyond Your Scope (Essential)****

• Ophthalmology (papilledema, need for glasses)
• Sleep Specialist/ENT (parasomnias, obstructive sleep apnea - CPAP or tonsil/adenoidectomy)
• Dentistry (TMJ, cavities, wisdom teeth)
• Neurosurgery (mass, symptomatic Chiari Malformation, bleed, aneurysm, thrombus)
• Physical Therapy, Gentle Chiropractor, Massage
• Counselor/Pediatric Psychiatry

7. Refine Your Diagnosis

      A. Primary Headache Disorders

• Pediatric Migraine with or without Aura
• Tension Type Headache
• Trigeminal Autonomic Cephalgias
• Hemiplegic Migraine
• Others (exercise induced, cough induced, thunderclap, etc.)

Migraine Episodic Syndromes

• Abdominal Migraine
• Cyclic Vomiting Syndrome
• Benign Paroxysmal Vertigo
• Benign Paroxysmal Torticollis

    B. Secondary Headache Disorders

• Trauma (accidental and non-accidental)
• Infection
• Substances
• Intracranial Mass
• Intracranial hypo/hypertension
• Epilepsy
• Sleep Apnea
• Side effects of medication
• Vascular
• Metabolic Abnormalities
• Psychiatric Causes

8. Communicate

• With colleagues involved in the patients care
• With the parents/family
• With the patient (important)
• Asking open ended questions and showing results – labs, study results, actual neuroimaging pictures
• This will help you partner with colleagues, the family and the patient to develop a successful and supportive treatment and care plan
• Remember a patient can have 2 or more diagnoses that all need to be addressed for optimal care

While caring for pediatric headache can appear daunting, adhering to evidence-based medical protocols can ensure the best care for your patient. Abnormalities found during the headache interview and exam that warrant further evaluations or outside referrals are easier manage by creating and maintaining a network of trusted healthcare providers in your area.

Citations

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