Headache

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

 

Aim 

To guide staff with the assessment and management of headache in children.

Background

Headache is a common symptom in children, affecting most children by 15 years of age3.

Common Causes are:

  • Systemic illness with fever
  • Tension Headaches
  • Cluster Headaches (older children)
  • Localised ENT problems
  • Migraine +/-Aura.

Uncommon but important causes:

  • Meningitis
  • Raised intracranial pressure (ICP) from tumours, bleeds etc.

 

Risk factors

Family history of migraine predisposes to migraine.

 

Assessment3

Assess headache as either acute or recurrent:

Acute Recurrent
  • Systemic with fever and general illness (e.g. viral illness, septicaemia, pneumonia)
  • Tension - bilateral band like pain, mild to moderate
  • Trauma
  • Sinusitis
  • Otitis media
  • Dental caries
  • Meningitis (fever, neck stiffness, photophobia)
  • Haemorrhage (sudden onset, severe pain, reduced conscious level, neck stiffness)
  • Migraine - aura, nausea, vomiting, visual disturbance, pallor, family history
  • Behavioural - consider family, school or social problems
  • Cluster - throbbing pain, possibly involving neck muscles usually unilateral and older children
  • Raised ICP - morning headaches ± vomiting, pain worse on coughing, sneezing or bending, personality changes, focal neurological symptoms 
  • Benign Intracranial Hypertension
  • Post-concussion headache (days - weeks)

History

Concerning features:

 

  • Headaches waking from sleep
  • Vomiting in the morning
  • Persistent visual disturbance
  • Sudden onset of headache (like being hit by a ball)
  • Motor weakness
  • Poor balance
  • Reduced LOC.
Migraine headache
  • Migraine is a type of headache common in children
  • Appear to be familial
  • Aggravated by exercise

Migraine triggers:

  • Various foods
  • Menstruation
  • Fatigue
  • Bright lights
  • Loud noises
  • Smoking
  • Drinking
  • Caffeine

Pain:

 

  • Dull or throbbing
  • Usually unilateral but can be bilateral
  • May range from mild to severe
  • Can last 1-72 hours

Child may also have:

 

  • Loss of appetite
  • Nausea or vomiting
  • Pale
  • Lethargy
  • Abdominal Pain

+/-Aura:

 

  • May precede headache
  • Visual disturbances
  • Sensory changes - pins and needles, numbness
  • Dysphasic speech
  • Usually last 5-60 minutes
Cluster headaches
  • Older children
  • Unilateral pain – may involve eye or nasal congestion and forehead sweating
  • Lasts up to 3 hours
  • Can be daily or up to 8 times per day
  • Causes restlessness and agitation
  • Can be severe
Tension headache
  • Bilateral
  • Mild – moderate severity
  • Tightening nature
  • Not aggravated by activities of daily living

Examination

  • The child may look:
    • well
    • unwell
    • septic
  • Full neurological assessment
  • Assess for local causes:
    • eye
    • sinus or ear
    • dental
    • cervical lymphadenopathy.

Investigations

Investigations are driven by likely diagnosis:

  • Sepsis or SAH - consider LP
  • Tumour or bleed - consider head CT
  • Migraine/tension headache - treat with appropriate analgesia

Management

Medications1,2,4

Analgesia
For all headaches
  • Paracetamol 20mg/kg stat then 15mg/kg/dose (max dose 1g) 4-6 hourly (max dose 4g/day)
  • NSAID - Ibuprofen 10mg/kg/dose (max dose 400mg) 8 hourly
  • Aspirin 600mg-1000mg in adolescents with migraine (give at same time as paracetamol)
Migraine and cluster headaches
  • Sumatriptan (serotonin agonist)
  • 5-20mg IN
  • 25mg orally (>12 Years)
  • Can be repeated after 30 minutes

In severe migraine or persistent headache, consider use of intravenous IV chlorpromazine hydrochloride4

Chlorpromazine hydrochloride

Administration of intravenous chlorpromazine hydrochloride1,2:

  • Use in children > 8 years old
  • Dose: 
    • 30-50kg: Use 6.25mg in 250mL of 0.9% saline over one hour
    • 50kg: Use 12.5mg in 500mL of 0.9%saline over one hour
  • Ampoules contain 50mg in 2mL
  • Chlorpromazine can prolong the QTc interval; this drug should be avoided in patients with cardiac disease, family history of sudden death, or potassium or magnesium deficiency (e.g. after persistent vomiting)

Monitoring the patient receiving intravenous chlorpromazine hydrochloride:

  • monitor BP, pulse and respiration every 15 minutes during the infusion and for 30 minutes after completion
  • continuous ECG and saturation monitoring
  • baseline neurological observations and continued hourly
  • chlorpromazine can cause dose dependent sedation, postural hypotension and restlessness
  • keep patient recumbent for the duration of the infusion and for 30 minutes after completion of dose

References

  1. AMH Children's Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2014 July. Available from: https://childrens.amh.net.au
  2. Australian Injectable Drugs Handbook, 6th Edition (online) Chlorpromazine Hydrochloride. The Society of Hospital Pharmacists of Australia. http://aidh.hcn.com.au.pklibresources.health.wa.gov.au/index.php/component/content/article/1-drug-monographs-a-z/70-section-70directory=3&itemid=8
  3. National Institute for Health and Care Excellence. Headaches: Diagnosis and Management of Headaches in Young People and Adults. Retrieved from www.nice.org.uk/guidance/cg150 on 11/08/14
  4. Kanis JM, Timm NL. Chlorpromazine for the Treatment of Migraine in a Pediatric Emergency Department. Headache: The Journal of Head and Face Pain 2014;54: 335-342

Endorsed by:  Director, Emergency Department   Date:  Mar 2018


 Review date:   Mar 2021


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