Headache in children: Approach to evaluation and general management strategies

INTRODUCTION — 

Headache is one of the most common complaints in children and adolescents, one of the top medical and neurologic disorders contributing to the global burden of disease, and a leading cause of disability in adolescents and young adults (ages 10 to 24 years) [1,2].

The prevalence of headache increases with age. Children with headache are usually brought to medical attention because they are missing school or social activities or their caregiver is concerned about an ominous etiology, including brain tumor or other serious disease. The first steps in the evaluation are a thorough history, physical examination, and neurologic examination. If any of these are abnormal or raise suspicion of a secondary etiology, then additional evaluation is indicated.

An overview of the causes, evaluation, and general management of headache in children will be presented here. Emergency evaluation of headache in children, specific primary headache syndromes in children, and headache related to exertion are discussed separately:

●(See "Emergency department approach to nontraumatic headache in children".)

●(See "Types of migraine and related syndromes in children".)

●(See "Pathophysiology, clinical features, and diagnosis of migraine in children".)

●(See "Acute treatment of migraine in children".)

●(See "Tension-type headache in children".)

●(See "Primary exercise (exertional) headache".)

EPIDEMIOLOGY — 

A complaint of headache is common in children and adolescents [3-5]. The estimated worldwide headache prevalence in children ages 3 to 18 years is nearly 60 percent [5]. In one national cohort of more than 10,000 children ages 4 to 18 years in the United States, 17 percent reported severe or recurrent headaches in the past 12 months [6]. The prevalence increased with age from 4.5 percent among children ages 4 to 6 years to 27 percent among children ages 16 to 18 years [6].

Before 12 years of age, the prevalence of headache among males and females is similar (approximately 10 percent) [6]. After age 12 years, the prevalence of chronic headache is higher in females (approximately 30 percent, versus 20 percent in males) [4,6]. In adults, the female-to-male ratio for migraine is approximately 3:1. The increase in ratio appears to occur during adolescence and young adulthood. Headaches occur more often in children who have a first- or second-degree relative with headache [7-9].

The epidemiology of migraine and tension-type headache (TTH) in children is discussed separately. (See "Pathophysiology, clinical features, and diagnosis of migraine in children", section on 'Epidemiology' and "Tension-type headache in children", section on 'Epidemiology'.)

CLASSIFICATION AND ETIOLOGY

Classification — Headaches are classified as either:

●Primary – Those in which the head pain is due to the headache condition itself (table 1)

or

●Secondary – Those in which the head pain is a symptom of an underlying condition

Primary and secondary headaches are not mutually exclusive; a patient may have a primary headache disorder that is exacerbated by a secondary etiology. In addition, a patient with a primary headache disorder may present with a new headache type that is due to an underlying cause.

Detailed diagnostic criteria for primary and secondary headaches are covered in the International Classification of Headache Disorders, 3^rd edition (ICHD-3) [10].

Etiology — Childhood headaches are rarely caused by a serious underlying disorder [11]. In the primary care setting, primary headaches (table 1) and infectious etiologies are the most common [12-14].

Most children who present to pediatric emergency departments with acute headache have a viral illness or an upper respiratory tract infection as the etiology. However, headaches without infectious etiologies (especially status migrainosus) are also evaluated in the emergency department, and more serious conditions are occasionally diagnosed [15-17].

Recurrent rhinosinusitis is one of the most common misdiagnoses for headaches, with the majority actually being a primary headache, usually migraine. As many as 90 percent of adults who have been diagnosed (self-diagnosed or diagnosed by a clinician) with recurrent sinus headaches actually have migraine headaches [18]. (See "Emergency department approach to nontraumatic headache in children", section on 'Causes'.)

Headache subtypes

●Primary headache – The most common primary headache types in children are migraine and tension-type headache (TTH) (table 1). Trigeminal autonomic cephalalgias (TAC) are uncommon in children.

•Migraine – Migraine is a disease characterized by intermittent attacks of headache (table 2A). Recognition that migraine is a disease in which headache is just one of the symptoms is important. A person does not have a "migraine" but rather has a headache due to migraine.

Chronic migraine is defined as headaches on 15 or more days per month, with at least eight of the headaches having migraine features. It is the most common chronic headache condition in children and adolescents and is more common in females than males (2.4 versus 0.8 percent) [19].

Migraine in children is discussed in detail separately. (See "Pathophysiology, clinical features, and diagnosis of migraine in children".)

•Tension-type headache – Although TTH may share clinical features with migraine, the ICHD-3 specifies that migraine diagnosis takes priority over the diagnosis of TTH. When in doubt between the two, the diagnosis of migraine, rather than "mixed headache disorder," should be made [10]. TTH in children is discussed in detail separately. (See "Tension-type headache in children".)

•Trigeminal autonomic cephalalgias (TAC) – Cluster headaches constitute the most common TAC. Cluster headaches have been reported in children as young as three years of age but are rare in children younger than 10 years. They become more common between the ages of 10 and 20 years, although they remain infrequent. This group of headaches is characterized by trigeminal location and association with autonomic features. Cluster headache is discussed in detail separately. (See "Cluster headache: Epidemiology, clinical features, and diagnosis".)

•Other primary headache – This category encompasses other headache disorders that are not caused by an underlying condition [10].

●Secondary headache – Secondary headaches are caused by an underlying condition. They usually develop in close temporal relationship to the underlying condition, and adequate treatment of the underlying condition usually leads to resolution of the headache. Secondary headaches include exacerbation of primary headaches by an underlying condition [20].

Conditions that may cause secondary headaches in children include [20]:

•Acute febrile illness (eg, influenza, upper respiratory infection, sinusitis) (see "The common cold in children: Clinical features and diagnosis" and "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis")

•Sinusitis with orbital or intracranial extension (table 3) (see "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Complicated ABRS')

•Bacterial or viral meningitis (see "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Clinical features' and "Viral meningitis in children: Clinical features and diagnosis", section on 'Clinical features')

•Acute encephalitis (see "Acute viral encephalitis in children: Clinical manifestations and diagnosis", section on 'Clinical features')

•Posttraumatic headaches (see "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation" and "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation")

•Subarachnoid hemorrhage (see "Emergency department approach to nontraumatic headache in children", section on 'Subarachnoid and intracranial hemorrhage')

•Idiopathic intracranial hypertension (IIH) (see "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis")

•Intracranial pathology (eg, brain tumor) (table 4) (see "Clinical manifestations and diagnosis of central nervous system tumors in children", section on 'Clinical manifestations')

Frequent overuse of analgesic medication is one of the most common contributors to chronic headache [21]. Medication overuse has been reported in 20 to 36 percent of adolescents with chronic headache and is an independent predictor of chronic migraine persistence [19,22-24].

Headache attributed to visual refractive error is included as a type of secondary headache in the ICHD-3, although it is rarely a contributor to headaches [10]. However, in contrast to the secondary causes of headache listed above, definitive evidence that visual refractive errors cause headaches in children is lacking [25].

CLINICAL PRESENTATION

General features — Young children may express pain differently than older children and adolescents, and they often are able to attenuate or ignore pain through play [26,27]. Headache pain may not be apparent to caregivers of younger children, who react to pain with nonspecific signs, such as crying, rocking, hiding, or altered activity level. Chronic pain may be associated with anxiety, depression, and problematic behavior, and it may affect the child's ability to eat, sleep, or play. Older children are better able to perceive, localize, and remember pain. The effects of emotional, behavioral, and personality factors on pain become more important as the child enters adolescence.

The variability in presentation in children of different ages may lead to difficulty when applying the standard headache diagnostic criteria (eg, International Classification of Headache Disorders, 3^rd edition [ICHD-3]) [10].

Primary headache

●Migraine – Characteristics of headache due to migraine in children include (table 2A) [10]:

•Bilateral location (bifrontal or bitemporal) in prepubertal children; often unilateral in adolescents

•Recurrent episodes of head pain that are typically moderate to severe in intensity

•Duration of 2 to 72 hours if not treated or unsuccessfully treated

•Throbbing pain that may worsen with activity or cause avoidance of activity

•May be accompanied by nausea, vomiting, light sensitivity ("photophobia"), and sound sensitivity ("phonophobia")

A diagnosis of migraine requires at least five headaches with characteristic features (table 2A).

An occipital location increases the risk of an underlying condition (although migraine remains the most common cause of occipital headaches) and requires further evaluation.

In children, particularly young children, the duration of headache is usually shorter (<2 hours) than in adults and steadily increases with age.

Approximately 10 percent of children with migraine have associated auras that include visual, sensory, speech/language, motor, brainstem, or retinal symptoms. These may be experienced as scotoma, paresthesia/numbness, dysphasia, and hemiplegia/weakness [28].

Episodic syndromes that may be precursors to and/or associated with migraine include benign paroxysmal vertigo, cyclic vomiting syndrome, abdominal migraine, colic, and benign intermittent torticollis (recurrent, often short-lived, and spontaneously recovering attacks of head tilt in infants) [29,30].

Additional conditions that are associated with migraine (oftentimes referred to as the periodic or episodic syndromes) include episodes of motion sickness, sleepwalking, sleeptalking, night terrors, unexplained fevers, recurrent abdominal pain, and episodes of anxiety. Motion sickness that is precipitated by reading in a car is a common feature in those with migraine. (See "Types of migraine and related syndromes in children", section on 'Episodic syndromes that may be associated with pediatric migraine' and "Acquired torticollis in children", section on 'Benign paroxysmal torticollis'.)

The clinical features of migraine in children are discussed in more detail separately. (See "Pathophysiology, clinical features, and diagnosis of migraine in children".)

●Tension-type headache (TTH) – Characteristics of TTH include (table 2B) [10]:

•Diffuse in location

•Non-throbbing

•Mild to moderate severity

•Does not worsen with activity (although the child may not wish to participate in activity)

•Lasts from 30 minutes to seven days

TTH may be associated with photophobia or phonophobia (not both) but is not accompanied by nausea, vomiting, or aura.

The clinical features of TTH in children are discussed in detail separately. (See "Tension-type headache in children", section on 'Clinical features'.)

●Trigeminal autonomic cephalalgias (TAC) – Characteristics of cluster headache, the most common type of TAC, include (table 2C) [10]:

•Location typically unilateral and frontal-periorbital

•Severe

•Duration less than three hours

•Multiple headaches occur in a short period of time (hence "cluster")

•Ipsilateral autonomic findings, such as:

-Lacrimation

-Conjunctival injection

-Nasal congestion and/or rhinorrhea

-Facial and forehead sweating

-Eyelid edema

-Miosis and/or ptosis

The clinical features of cluster headache are discussed in detail separately. (See "Cluster headache: Epidemiology, clinical features, and diagnosis", section on 'Clinical features'.)

●Other primary headache – Characteristics of these headaches vary and depend on the disorder. The ICHD-3 provides the clinical features of each disorder [10].

Secondary headache

●Viral illness – Respiratory and/or gastrointestinal symptoms

●Sinusitis with orbital extension (table 3) – Eyelid swelling and/or erythema; periorbital swelling and/or erythema; proptosis; pain with and/or limitation of eye movement; double vision and/or loss of vision

●Sinusitis with intracranial extension (table 3) – Ptosis; proptosis; limitation of eye movement; bilateral periorbital edema; change in mental status; fever; forehead or scalp swelling and tenderness; photophobia; vomiting; lethargy; papilledema

●Bacterial or viral meningitis – Fever; headache; nuchal rigidity; photophobia; nausea/vomiting; confusion; lethargy; irritability; Kernig sign; Brudzinski sign

●Encephalitis – Fever; change in mental status; coma; seizures; irritability, emotional lability, or unusual behavior; cranial nerve palsies; abnormal movements; weakness

●Acute posttraumatic headache – Begins immediately following head trauma; usually resolves within 7 to 10 days

●Subarachnoid/intracranial hemorrhage – Sudden onset; severe (often described as "worst headache of my life"); unilateral; maximal intensity in <1 minute; brief loss of consciousness; vomiting

●Idiopathic intracranial hypertension (IIH) – Diplopia; sixth cranial nerve palsy; papilledema; intracranial noises/pulsatile tinnitus (may hear rushing water or wind); patients often overweight or have had recent weight gain; may be caused by some medications (eg, tetracycline)

●Intracranial pathology (eg, tumor, other space-occupying lesion) (table 4) – Awakens child from sleep or consistently present upon awakening; brief or paroxysmal headache; persistent nausea/vomiting; altered mental status; occurs or worsens while supine; chronic and progressive symptoms; occipital location

DIAGNOSTIC EVALUATION — 

The evaluation of headache in children requires a thorough history (table 5), general physical examination (table 6), and neurologic examination with particular attention to the clinical features suggestive of intracranial infection or space-occupying lesion (table 4). If the initial evaluation raises suspicion of secondary headache, additional diagnostic testing may be necessary. An abnormality on the neurologic examination is the most sensitive indicator of need for further evaluation, including neuroimaging. The headache pattern may help determine the etiology.

Most children who present to primary care with recurrent headaches have primary headaches or headache due to an uncomplicated viral illness and do not require neuroimaging [14]. Neuroimaging generally is not indicated for children with a history of recurrent, episodic headaches that have persisted for greater than six months and who have no signs or symptoms of neurologic dysfunction or increased intracranial pressure [31,32]. Headache features and frequency may vary with time, so the full history must be utilized to guide neuroimaging decision-making.

Neuroimaging of children with headaches in the absence of neurologic abnormalities on examination and/or symptoms of neurologic abnormalities on history has a low yield of clinically significant findings (0.9 to 1.2 percent) [31,33,34]. Neuroimaging of such children may detect incidental findings that require additional evaluation or follow-up [33,35-38]. Other potential adverse effects include unnecessary radiation exposure or exposure to anesthesia if sedation is required [32].

History

●General history – The general history in a child with headache includes (table 5) recent change in weight, vision, sleep, exercise, and diet; other medical conditions; psychosocial stressors; family and social history; and medications that may cause idiopathic intracranial hypertension (IIH).

●Headache history – The headache history is the most valuable component of the diagnostic evaluation (table 5). A thorough history helps to focus the physical examination and prevent unnecessary further investigation, including neuroimaging.

The history should first be obtained from the child and then confirmed by the caregivers. In young children, caregiver observation of behaviors contributes to characterization of the headache. Asking young children to "draw the headache" is another useful strategy when a child is not able to express the headache characteristics in words.

Ask all patients questions about (table 5):

•Age at onset

•Type of onset (eg, gradual, sudden)

•Headache frequency

•Headache duration (shortest, longest, and average)

•Presence of aura or prodrome

•Headache present upon awaking from sleep

•Headache location

•What makes headache worse

•What makes headache better

•Whether activity improves or worsens the headache

•Associated symptoms

•Quality of the headache (eg, pressure, squeezing/tight band, throbbing/pulsating, dull/aching)

Ask if any headaches are accompanied by neurologic symptoms, such as hemiplegia or ophthalmoplegia.

●Headache diary – Assigning a headache diary may provide additional information if the child is willing and able to complete it daily. Useful components of a headache diary include:

•Quality

•Location

•Severity

•Timing

•Precipitating and mitigating factors

•Associated symptoms

A diary is not subject to recall error and may reveal a pattern that is typical for a certain type of headache. A diary may also provide important diagnostic information, especially when a child has difficulty providing sufficient detail during the office interview [39,40].

●Headache pattern – Determining whether a headache is new or represents a recurrent problem is useful in differentiating primary from secondary headaches. Most primary headaches are episodic headaches that may transform to more frequent headaches. Asking about all headaches, not just the one that is being brought to attention, can help identify this pattern. An acute change in an underlying recurrent, episodic headache disorder is a potentially concerning pattern.

Physical examination — The components of the physical examination are detailed in the table (table 6) [41]. Children with primary headaches (eg, migraine, tension-type headache [TTH]) usually have a normal physical examination, although children and adolescents with migraine may have a higher presence of hypermobility syndrome [42]. (See "Pathophysiology, clinical features, and diagnosis of migraine in children", section on 'Diagnosis' and "Tension-type headache in children", section on 'Examination'.)

The physical examination is typically normal in secondary headaches as well. Yet, when any part of the physical examination (especially the neurologic examination) is abnormal, secondary headaches must be considered. Abnormal examination findings may provide clues to the underlying diagnosis.

●General examination – Essential components of the general examination include:

•Blood pressure and temperature

•Head circumference for children under age two

•Height and weight measurements and trajectories

•Auscultation for bruits of the neck, eyes, and head

•Palpation of the head and neck

●Neurologic examination – A comprehensive neurologic examination should be performed on any child presenting with headache, paying particular attention to the following components:

•Mental status examination

•Skull, spine, and meninges

•Cranial nerve assessment, including:

-Visual field testing

-Eye movements

-Funduscopy (especially looking for papilledema)

•Motor examination

•Sensory examination

•Coordination

•Deep tendon reflexes

•Station and gait

Additional evaluation for signs and symptoms consistent with primary headache

●Headache with abnormal neurologic signs or symptoms – Neuroimaging of the brain to evaluate for an intracranial process is indicated when abnormal neurologic signs (eg, persistent weakness, seizures, persistent altered mental status) accompany the headache. In nonurgent circumstances, we prefer magnetic resonance imaging (MRI) because it minimizes radiation exposure and is more sensitive than head computed tomography (CT). However, when MRI is not available, CT is performed.

●Headache with occipital location – MRI of the brain to evaluate for an intracranial process is indicated when headache pain is exclusively occipitally located. However, this indication is starting to be questioned [43].

●Primary headache without abnormal neurologic signs or symptoms – No additional evaluation is indicated. However, if new symptoms develop or changes in symptoms occur, the child should be reevaluated.

●Young age (or children unable to fully describe headaches) – For children ≤6 years old, imaging is indicated, as they may not be able to fully describe their headaches.

Additional evaluation for signs and symptoms consistent with secondary headache — The decision to pursue additional diagnostic evaluation is made on a case-by-case basis (algorithm 1).

Presence of focal neurologic findings or altered sensorium — The presence of any abnormal neurologic findings on physical examination requires neuroimaging, usually with an MRI.

Features consistent with intracranial pathology — The presence of other headache features consistent with intracranial pathology (eg, awakens child, worse in recumbent position, occipital in location) requires an MRI with gadolinium unless signs and/or symptoms of a space-occupying lesion are progressing rapidly. In such a situation, a CT with contrast is preferred (table 4).

Suspected subarachnoid hemorrhage (eg, "thunderclap headache") — These patients require a noncontrast head CT. This should be followed by a lumbar puncture (LP) if the CT does not show signs of hemorrhage, mass effect, or evidence of an alternative etiology. (See "Emergency department approach to nontraumatic headache in children", section on 'Subarachnoid and intracranial hemorrhage' and "Overview of thunderclap headache" and "Overview of thunderclap headache", section on 'Evaluation for subarachnoid hemorrhage'.)

Papilledema or medications associated with idiopathic intracranial hypertension — Children with headache who have papilledema, have recently discontinued glucocorticoids, or use medications associated with IIH (eg, growth hormone, tetracyclines, excessive doses of vitamin A) require all of the following:

●Neuroimaging, usually an MRI, to evaluate for other causes of increased intracranial pressure

●LP to determine the opening pressure (OP); OP ≥280 mmH₂O is abnormal

●Ophthalmologic evaluation to verify the presence of papilledema, grade its severity, and assess the presence and severity of optic nerve damage

Straining or crying can cause artificially high OP measurements. These children may require reassurance or sedation before undergoing the LP because an accurate OP measurement is crucial to the diagnosis.

The evaluation of IIH is discussed in greater detail elsewhere. (See "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis".)

Symptoms consistent with meningitis or viral encephalitis — LP is indicated when meningitis or encephalitis are suspected. A CT should precede the LP if an intracranial process that would preclude an LP or an impending herniation is suspected. This is discussed in more detail elsewhere. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis" and "Acute viral encephalitis in children: Clinical manifestations and diagnosis", section on 'Clinical features'.)

Whether or not a CT is performed prior to LP, an MRI with and without gadolinium is indicated as part of the evaluation of encephalitis. MRI is more sensitive than CT for detecting neuroradiologic findings of encephalitis. (See "Acute viral encephalitis in children: Clinical manifestations and diagnosis", section on 'Neuroimaging'.)

Sinusitis with symptoms consistent with orbital or intracranial extension — A CT with contrast of the orbits, sinuses, and brain is indicated when a complication of sinusitis is suspected. This is discussed in more detail elsewhere. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Complicated ABRS'.)

Severe headache and a chronic condition that predisposes to intracranial pathology — A child with severe headache who also has a chronic condition that predisposes to intracranial pathology requires neuroimaging, usually with an MRI. These conditions include:

●Immune deficiency

●Sickle cell disease

●Neurofibromatosis

●History of neoplasm

●Coagulopathy

●Hypertension

Age ≤6 years — Headache in a child ≤6 years of age requires neuroimaging, usually with an MRI.

Acute posttraumatic headache — If headache persists beyond 7 to 10 days, refer to a neurologist or headache specialist.

DIAGNOSIS

●Primary headache – The diagnosis of primary headache disorders is made clinically, based upon the International Classification of Headache Disorders, 3^rd edition (ICHD-3) [10] (see 'Headache subtypes' above):

•Migraine (table 2A)

•Tension-type headache (TTH) (table 2B)

•Trigeminal autonomic cephalalgias (TAC), including cluster headaches (table 2C)

The diagnosis of chronic headache is made when a child has a headache on more than 15 days a month for more than three months.

●Secondary headache – The diagnosis of a secondary headache disorder relies upon the identification of the underlying condition. (See 'Headache subtypes' above.)

OVERVIEW OF THE MANAGEMENT OF PRIMARY HEADACHE — 

The management of recurrent and chronic headache in children and adolescents depends upon the underlying etiology. Management of primary headache (eg, migraine, tension-type headache [TTH]) is discussed separately. (See "Acute treatment of migraine in children" and "Tension-type headache in children", section on 'Treatment' and "Cluster headache: Treatment and prognosis", section on 'Approach to therapy'.)

Nonpharmacologic management — Components of nonpharmacologic management of recurrent headache disorders include [44-47]:

●Providing realistic expectations (ie, the frequency and severity of the headaches may decrease over weeks to months of therapy, but the headaches may continue to occur)

●Return to school for children who have been absent; if necessary, they can go to the school nurse or office once daily for 15 minutes when headache pain peaks

●Avoidance of headache triggers (eg, caffeine, lack of sleep or irregular sleep, inadequate hydration)

●Improved diet with avoidance of prolonged fasting

●Daily exercise for 30 to 45 minutes

●Addressing comorbid sleep problems (eg, delayed sleep onset, frequent night waking), mood problems, and/or anxiety

Additional nonpharmacologic approaches may be beneficial. Cognitive behavioral therapy and biofeedback-assisted relaxation therapy including guided imagery, progressive muscle relaxation, and deep breathing have some evidence of benefit. Other treatments (including physical therapy, acupuncture, hypnosis, meditation, and massage) may be helpful but are unproven [45,48-50].

Several devices have been approved by the US Food and Drug Administration for the acute and preventive treatment of headaches due to migraine. These devices (which provide mild electrical stimulation to the face, head, or upper arm) offer the additional benefit of allowing the patient to have an increased locus of control while avoiding the need to swallow medications.

Pharmacologic management — The use of over-the-counter analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, to treat acute headaches in children and adolescents is a key component of management. However, patients and caregivers should be instructed to limit the use of analgesics to no more than 14 days per month to reduce the risk of developing medication overuse headache (MOH) [19,21-24]. For patients who develop MOH, management typically involves weaning or discontinuing the overused medication. These issues are discussed separately. (See "Acute treatment of migraine in children", section on 'Avoiding medication overuse' and "Medication overuse headache: Treatment and prognosis", section on 'Wean the overused medication'.)

Preventive medications may be warranted for some patients with headaches that are frequent, long lasting, or disabling. The role of preventive therapy in children with migraine or TTH is discussed in greater detail separately. (See "Preventive treatment of migraine in children", section on 'Pharmacologic treatment' and "Tension-type headache in children", section on 'Preventive treatment'.)

INDICATIONS FOR REFERRAL — 

Primary care providers are usually able to manage children and adolescents with acute, recurrent, episodic, and chronic headaches. Indications for referral may include [12,51]:

●Secondary headache requiring specialist management (eg, space-occupying lesions, idiopathic intracranial hypertension [IIH])

●Headaches associated with mood disturbance or anxiety

●Uncertain diagnosis

●Headaches refractory to primary care management

●Frequent headaches unresponsive to typical therapy (ie, chronic migraine or chronic tension-type headache [TTH])

●The need for more intensive management that can be provided only by a multidisciplinary headache program

RESOURCES

●The American Migraine Foundation provides information and resources for patients and providers.

●The American Headache Society provides resources for clinicians.

●The National Headache Foundation provides information and resources for patients and providers.

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Headaches in children (The Basics)" and "Patient education: Migraine in children (The Basics)")

●Beyond the Basics topic (see "Patient education: Headache in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Epidemiology – Approximately 20 percent of children aged 4 to 18 years have frequent or severe headaches, which are often chronic. Before 12 years of age, the prevalence of headaches among males and females is similar. After age 12 years, the prevalence of chronic headache is higher in females. (See 'Epidemiology' above.)

●Etiology – Headache in children and adolescents may be due to a primary headache disorder (ie, migraine, tension-type headache [TTH], trigeminal autonomic cephalalgias [TAC] (table 1)) or secondary to an underlying medical condition.

Secondary headaches usually are related to fever or infection (eg, upper respiratory infection, influenza) but may be due to central nervous system infection, space-occupying lesion, or other pathologic process. (See 'Classification and etiology' above.)

●Diagnostic evaluation

•The evaluation of headache in children requires a thorough history (table 5), physical examination (table 6), and neurologic examination, with particular emphasis on clinical features suggestive of intracranial pathology (table 4). The headache pattern helps to determine the etiology. (See 'History' above and 'Physical examination' above.)

•Most children who present to primary care with headaches have primary headaches or headaches due to an uncomplicated viral illness and do not require neuroimaging. The decision to obtain neuroimaging is made on a case-by-case basis and depends upon what type of etiology the signs and symptoms suggest. (See 'Additional evaluation for signs and symptoms consistent with secondary headache' above.)

•The need for additional diagnostic evaluation (eg, lumbar puncture [LP], laboratory tests) of secondary headache is based on the underlying condition, which is suggested by information from the history and physical examination. Routine laboratory evaluation usually is not necessary or helpful for children with recurrent or chronic headaches. (See 'Additional evaluation for signs and symptoms consistent with secondary headache' above.)

●Diagnosis – The diagnosis of primary headache disorders is made clinically, based upon the criteria of the International Classification of Headache Disorders, 3^rd edition (ICHD-3) (table 2A-C). The diagnosis of secondary headaches depends upon identification of the underlying condition. (See 'Diagnosis' above.)

●Management – The management of recurrent and chronic headaches in children and adolescents depends upon the underlying etiology. It consists of nonpharmacologic and pharmacologic treatments. (See 'Overview of the management of primary headache' above.)

For patients who develop medication overuse headache (MOH), management typically involves weaning or discontinuing the overused medication. (See "Acute treatment of migraine in children", section on 'Avoiding medication overuse' and "Medication overuse headache: Treatment and prognosis", section on 'Wean the overused medication'.)

Preventive medications may be warranted for some patients with headaches that are frequent, long lasting, or disabling. (See "Preventive treatment of migraine in children", section on 'Pharmacologic treatment' and "Tension-type headache in children", section on 'Preventive treatment'.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Andrew G Lee, MD, who contributed to earlier versions of this topic review.