Headaches are a common reason for pediatric visits to the emergency department. Emergency clinicians must distinguish between common and dangerous secondary causes of headache and primary headache disorders such as migraine and tension-type headaches.
Our recent issue Emergency Department Management of Primary Headache Disorders in Pediatric Patients discusses the diagnosis of primary headaches by history and physical examination, the options for first-line treatment of primary headache and for severe or refractory migraines, and procedural interventions that may be considered when other therapies have failed.
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Here are a few key points:
- Headaches can be categorized as primary or secondary. Primary headache disorders are characterized by headaches as the primary pathology, without structural or systemic causes (eg, migraine and tension-type headache). Secondary headaches are a symptom of another condition (eg, trauma, infection, or systemic disease).
- The emergency clinician must differentiate between primary headache disorders and secondary headaches of serious or life-threatening etiology.
- Pediatric migraine differs slightly from adult migraine: episodes can be shorter, pain is often bifrontal rather than unilateral, and symptoms such as photophobia and phonophobia may be inferred by caretakers from behavioral cues.
- Migraine with aura has an earlier onset (7-9 years of age) than migraine without aura, which is more common overall.
- The American Headache Society systematic review and evidence-based recommendations for neuroimaging in childhood migraine states that neuroimaging is not necessary for patients with headaches consistent with migraine or probable migraine who have a normal neurologic examination. The American College of Radiology Appropriateness Criteria® list all forms of imaging as “usually not appropriate” for primary pediatric headache.
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