Headaches

Introduction

Headaches can be categorised into two types:

Primary Headaches

Where the headaches occur on their own not from another underlying medical condition. ^{(1, 2, 3, 4, 5, 6, 7)}

These include migraines, cluster headaches, tension headaches, chronic daily headaches. ^{(1, 2, 3, 4, 5, 6, 7)}

Secondary Headaches

Where the headaches are due to an underlying medical condition. ^{(3, 5, 6)}

These include tumours, vascular lesions, hydrocephalus, sinusitis, viral infections etc. ^{(3, 5, 6)}

Pre-referral history, examination and investigations

Clinical history including:

• Duration and frequency
• Location and nature of pain
• Worsening severity
• Associated features (nausea and vomiting, neurological signs)
• Exacerbating and relieving factors
• Effect on the level of daily functioning (e.g. missing/affecting school or usual activities, affecting sleep)
• Significant analgesia use

Symptoms requiring further investigation:

• Seizures (see Seizure pre-referral guideline)
• Abnormal growth or puberty
• Known underlying medical disorder

Physical examination including:

• Growth parameters (e.g. Increasing head circumference)
• Blood pressure
• Neurological examination (for focal abnormalities or signs of raised intracranial pressure – papilloedema, strabismus, focal weakness, abnormal reflexes, ataxia, altered mental state)
• Neck stiffness or photophobia
• For older child / adolescent, consider MRI brain at time of referral if significant concern

For more information on headache management guidelines, see Health Pathways-Headaches in Children

Pre-referral management

• Lifestyle advice
  • Improving sleep hygiene and educate on adequate sleep hours for age
  • Eating regular meals and having adequate hydration
  • Encourage usual activities and exercise as tolerated
  • Learning relaxation techniques
  • Keeping a headache diary (see useful resources below)
  • Avoid triggers
• Pharmacological therapy
  • Simple Analgesia- paracetamol and ibuprofen
    • Limit to 3 times a week to prevent medication overuse headache
• Consider Sumatriptan if migraine suspected ≥10 year old (in conjunction with simple analgesia)
• If neurological symptoms are suspected to be due to underlying pathology such as a space occupying lesion or hydrocephalus, please present to the nearest Emergency Department
  • If sufficient concern, consider MRI brain
  • A GP can order an MRI of the head for any patient under the age of 16 with specific neurological symptoms as per the Medicare Benefits Schedule (MBS)

When to refer

• Refer to PCH General Paediatrics Department if:
  • MRI results are abnormal
  • Child is having recurring headaches and not responding to initial GP management
  • Child is presenting with a headache and any red flag sign in the box above

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service
• Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals go to the PCH Referral Office
• Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call PCH Switch on 6456 2222 to discuss referral with the on-call General Paediatrician

Essential information to include in your referral

• Relevant medical history including detailed history of headaches
• Any concerning features
• All treatment trialled and current management
• Results from any tests performed
  • If a specific test result is unable to be obtained due to access, financial, religious, cultural or consent reasons, please state in referral

References

1. Parisi P, Papetti L et al. Tension type headache in paediatric age. Acta Paediatrica 2011; 100:491-495
2. Stuart Lewis K. Pediatric headache, Seminars in Pediatric Neurology 2010; 17:224-229.
3. Özge A, Termine C et al. Overview of diagnosis and management of paediatric headache. Part 1: diagnosis, 2010. Journal of headache and pain; 12: 13-23.
4. Whitehouse WP, Agrawal S. Management of children and young people with headache, Archives Disease Childhood Educ Pract Ed 2017;102:58– 65
5. Seshia SS. Chronic daily headache in children and adolescents, 2012. Current pain headache rep; 16:60-72.
6. Termine C, Özge A et al. Overview of diagnosis and management of paediatric headache. Part II: therapeutic management, 2011. Journal of headache and pain; 12: 25-34
7. Clinical Practice Guidelines : Headache (rch.org.au) https://www.rch.org.au/clinicalguide/guideline_index/Headache/

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