Nearly all brain tumours and other secondary headaches can be identified on the basis of the history and examination alone.

History

Determine whether the patient gets more than one type of headache, and for each type establish the following seven features of a typical headache attack:

• Location
• Quality – e.g. throbbing, stabbing
• Intensity – e.g. can function with pain or incapacitated by it
• Frequency
• Duration
• Other features – e.g. nausea, vomiting, aura, photophobia, phonophobia, autonomic features
• Effect on other activities (e.g. has to stop)

Determine whether red flags are present – see below

Establish a drug history including frequency of analgesic / triptan use. More than 2 doses of analgesic use per week carry a risk of medication overuse headache

Determine the headache pattern. Generally, intermittent headaches (however frequent) with complete recovery in-between indicate primary headache. Progressive headache with other new symptoms are more suggestive (but not diagnostic of) a secondary cause.

A diary can help to identify triggers for headaches.

Examination

• General examination including height, weight, head circumference (OFC) in under 5 year olds, birthmarks, blood pressure
• Scalp, neck + upper back for scoliosis, tenderness
• Cranial nerves to include visual fields and fundoscopy. Look for a head tilt (IVth nerve lesion) or new squint
• Look for asymmetry of tone, power + reflexes
• Test for signs of ataxia, including gait

Headache which:

• occurs in a child under 3 years of age
• wakes a child / young person from sleep, especially with vomiting
• is located in a fixed or unusual location
• is triggered by postural change or cough, straining, laughing
• is sudden and severe in onset
• is associated with fever or coma
• comes with academic decline or personality change in older children, or irritability in young children
• develops alongside new neurological symptoms e.g. visual loss, new squint, or loss of balance
• is associated with new neurological signs on examination, or is associated with faltering growth (young children)
• changes substantially and / or suddenly

Where red flags are absent, the likelihood of brain tumour being present is 0.03%

See 'diagnosis' for epidemiology of headaches and brain tumours, below.

• Where red flags are absent, the likelihood of brain tumour being present is 0.03%
• Where red flags are absent, determine the primary headache type/s according to the headache features in the table:

1. Some headaches are 'unclassifiable', especially in young children who cannot describe their headaches. Even so, most unclassifiable headaches are primary in origin
2. Tension-type and migraine headaches can occur concurrently in the same patient. The relative incidence can vary over time
3. Where tension-type headache develops alongside migraine, consider medication overuse
4. Aura symptoms occur in only 15% of migraine in childhood / adolescence

• Headaches with no red flags do not need neuro-imaging
• Do not refer for/undertake a brain scan in primary headache for reassurance

Information and support for children and young people with headache disorders

1. Openly explore and address parental / patient concerns about secondary headache (especially brain tumour). Explaining why you think this is unlikely to be the cause of headache (duration of headache disorder, timing of headaches, lack of findings on examination) is likely to reduce anxiety and help with coping with the headache problem, at least in the short term
2. Include the following in discussions with the child / young person and their carer:
   • A positive diagnosis including an explanation of the type of headache and reassurance that other pathology has been excluded and
   • Recognition that headache is a valid medical disorder that can have a significant impact on the child / young person, but that there is a good chance of improvement with time without preventative treatment and
   • Options for management
3. Direct the family towards supportive information online, for example Migraine Trust
4. Explain the risk of medication overuse headache to children and young people who are using acute treatments for their headaches
5. Counsel that any change in the headache nature especially with new red flags should trigger another GP review

Principles of management of primary headaches

These are threefold:

• Acute management
• Lifestyle modifications
• Preventative treatment

Tension-type headaches

• Acute management
  • Paracetamol / ibuprofen used sparingly where needed, remembering the risk of medication overuse headache where analgesics are used more than twice per week
  • Self-management includes distraction (especially in young children), topical remedies (e.g. 4Head, Tiger Balm), relaxation, take a walk
  • Encourage staying at school
• Lifestyle modifications
  • Attention to triggers e.g. self-exerted pressure and mood disorders – school counsellor may help
  • Increase exercise
  • Regular sleep
  • Avoid skipping meals, limit caffeine
• Preventative treatment
  • Consider acupuncture for children over 12 years where chronic tension-type headache is present and other interventions have not worked. This is not available via paediatric services
  • No evidence of benefit of any medication

Migraine with / without aura

Please refer to the formulary guidance on management of migraine in children

• Acute management
  • Rest / sleep where needed
  • Prompt use of NSAID, for example ibuprofen
  • Offer co-use of prochlorperazine, cinnarizine or domperidone where prompt use of NSAIDs alone fails
  • Consider adding or replacing with sumatriptan (unlicensed under 12 years of age) 10mg by nasal spray. Sumatriptan nasal spray is licensed in children aged 12 years or over; oral sumatriptan is occasionally recommended by specialist paediatricians for off-label use, more information can be found in the BNF for children.
  • Where analgesics, sumatriptan is only partly effective, check they are being used promptly and correctly.
    • Correspondence for school advising on individual acute management may be required
• Lifestyle modifications
  • Recommend regular sleep
  • Avoid skipping meals
  • Regular exercise with adequate hydration
  • Sunglasses / cap for light-induced migraine, limit caffeine
  • Attention to triggers e.g. self-exerted pressure and mood disorders – school counsellor may help
  • No evidence of benefit of exclusion diets
• Preventative treatment
  • Explain that there is no curative treatment and that none is certain to work. Most children do not need this if acute management is adequate and lifestyle modifications can be taken on board

Where needed, discuss the benefits and risks of prophylactic treatment for migraine with the child / young person, taking into account their parent or carer's views, own preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life.

• Consider propranolol or topiramate as first line preventative treatment, which have the best evidence base, over 12 years of age
• Advise girls over 12 years that topiramate is associated with a risk of foetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception if needed
• There are no high quality trials of any migraine preventative treatment under 12 years of age. Alternatives to the above include pizotifen, amitriptyline. Do not use Gabapentin (side effects) or Valproate (teratogenicity, side effects)
• For people who are already having treatment with another form of prophylaxis and whose migraine is well controlled, continue the current treatment as required
• Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment
• Oral contraceptives are rarely needed or useful in migraine in young women under 18 years, and are contraindicated in migraine with aura

Mixed Tension-Type Headache and Migraine

Co-morbid migraine and tension-type headache are extremely common

• Whilst substantial or sudden change in headache type is a red flag, it is usual for young people's predominant primary headache type to vary repeatedly over time particularly in chronic tension-type headache or chronic migraine
• Consider medication overuse headache as a possible cause where analgesics are used more than twice a week (see below)
• Acute treatment
  • Treat only the migraine headaches, as above
  • Aim to prevent frequent analgesic use of tension-type headache as this may lead to medication overuse
  • Consider topical treatment for tension-type headache
• Lifestyle modification
  • As above for migraine
• Preventative treatment
  • As above for migraine, where required

Medication Overuse Headache (MOH)

The key to successful treatment is explanation of the problem and what the child / young person and family can expect:

• Overuse of symptomatic treatments for headache may be the cause of, or can contribute to, chronic headache
• MOH is treated by withdrawing the overused medication
• Headache symptoms are likely to get worse before they improve. Withdrawal headache typically lasts between 2 and 3 weeks, and may be associated with other symptoms such as restlessness, nausea
• Withdrawal of overused medication will result in either complete resolution of the headache (if MOH is the only cause of the headache) or return to the original headache type (if frequent medication had been used to treat this type)
• Most people can withdraw successfully with the right support and encouragement

Advise the child / young person / parent or carer:

• To stop all analgesic medication (including triptans) abruptly for at least 1-2 months (opioids should be slower if in use)
• Consider migraine preventative treatment, if migraine was present prior to medication overuse headache, to facilitate analgesic withdrawal
• Offer follow-up appointment in 1-2 months to provide support during withdrawal
• If no response to withdrawal reconsider the primary headache diagnosis

Short Severe Headaches

These are uncommon. Seek specialist advice.

Devon Formulary Chapter 4 Central Nervous System – Management of migraine

Referral Criteria

Emergency referral if:

• Acute headaches with fever or coma contact the acute paediatrics via the on-call team

Urgent referral:

• All other red-flag headaches for review within 2 weeks

Routine referral if:

• Other headaches for which the primary headache type is unclear / short and severe / not described in this guideline, and / or where the management plan cannot be followed

Referral Instructions

To refer as emergency:

• Contact the acute paediatrics via the on-call team

To refer as urgent/routine:

e-Referral selection:

• Priority: Urgent/Routine
• Speciality: Children's & Adolescent Services
• Clinic type: Neurology
• Service: DRSS-South Devon & Torbay-Children's & Adolescent Services- Devon ICB - 15N

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Migraine Trust – information for young people

My Cleveland Clinic – information for families on a number of childhood / adolescent conditions – look for 'headaches in children and adolescents'

Evidence

NICE Guidance on Headaches in over 12's (CG150), 2012

NICE Clinical knowledge summary on Medication Overuse

Fifteen minute consultation: headache in children under 5 years of age, McCrea N, Howells R. Arch Dis Child Educ Pract Ed 2013;98: 181–185.

Pathway Group

This guideline has been signed off by South Devon and Torbay locality on behalf of NHS Devon CCG

Publication date: August 2017