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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Headache, migraine and raised-intracranial-pressure red flags

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Headache with neurological deterioration

Reduced consciousness, meningism, non-blanching rash, acute focal deficit, papilloedema, thunderclap onset, hypertensive emergency or signs of impending herniation requires immediate hospital assessment.

Action: Use ABCDE, check glucose and blood pressure, obtain senior paediatric and neurological help, treat suspected infection promptly and arrange urgent imaging before lumbar puncture when raised intracranial pressure makes puncture unsafe.

Overview

Make a positive age-appropriate headache diagnosis, recognise infection and raised intracranial pressure early, use fundoscopy and blood pressure correctly and manage childhood migraine without unnecessary imaging.

Ask the child as well as the caregiver. Establish sudden or gradual onset, first or worst episode, frequency trend, waking from sleep, morning symptoms, posture or Valsalva effect, duration and recovery. Record vomiting, visual obscuration, diplopia, aura, weakness, fever, neck symptoms, seizure, trauma, carbon-monoxide exposure and use of analgesics, caffeine or hormonal medicines.

Observe behaviour, gait, head posture and eye movements before formal examination. Measure temperature and age-appropriate blood pressure, then assess visual acuity, fields, pupils, ocular alignment, upgaze, optic discs, cranial nerves, power, reflexes, coordination and gait. In infants, measure head circumference and examine the fontanelle.

Migraine is a positive clinical diagnosis. Children may have shorter, bilateral attacks with nausea, pallor, photophobia and movement avoidance. Migraine aura evolves gradually and resolves fully. Tension-type headache is usually bilateral and pressing without worsening on ordinary activity. Do not

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Paediatrics and child healthOriginal SBA

Immediate red-flag referral

A nine-year-old has headaches that wake him at night, morning vomiting and new unsteadiness. What is the most appropriate next action?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG127 Neurological RecognitionImmediate headache red flags and paediatric neurological referral thresholds.
  • NICE CG150 Headaches GuidelineMigraine diagnosis, acute treatment, prevention and medication overuse from age 12.
  • NHS Migraine OverviewMigraine symptoms, urgent warning features and patient self-care.
  • Better Safe Than Tumour Childhood SignsUK age-specific childhood brain tumour symptom awareness.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
let a family history erase a new red flag.

Raised intracranial pressure may cause waking or early-morning headache, vomiting, sixth-nerve palsy, papilloedema, ataxia or declining consciousness, but no single symptom is universal. Posterior fossa disease can present with vomiting, imbalance or squint before a child can describe headache. Papilloedema can be absent early, so a normal disc does not negate other serious signs.

Investigation follows urgency. Emergency CT can rapidly detect haemorrhage, hydrocephalus or mass effect in an unstable child. MRI gives better posterior fossa and parenchymal detail when clinically safe. Do not perform lumbar puncture when focal signs, papilloedema or impaired consciousness suggest pressure-related herniation risk. Suspected idiopathic intracranial hypertension needs specialist imaging and venous assessment before pressure measurement.

Management combines an early acute medicine, rest, hydration and antiemetic when needed, plus regular sleep, meals and exercise. Limit acute medicine days to reduce overuse. Preventive options such as propranolol, topiramate or amitriptyline require paediatric specialist selection, comorbidity and reproductive review; topiramate has stringent pregnancy-prevention restrictions.

Key points

  • Headache diagnosis begins with age, time course, waking pattern, triggers, duration, location, associated symptoms, medication exposure and a complete neurological examination.
  • In children under 12, NICE red flags such as waking headache, morning headache, progression, cough or bending trigger, vomiting, ataxia, lethargy or altered consciousness require immediate same-day assessment.
  • Measure blood pressure with the correct cuff and perform fundoscopy for recurrent headache; inability to visualise the fundus when raised pressure is plausible warrants competent reassessment, not assumed normality.
  • Migraine in children may be bilateral and last 2–72 hours; younger children often stop playing, seek sleep or show pallor rather than describing pulsation and photophobia precisely.
  • Typical aura develops gradually over at least five minutes, lasts 5–60 minutes and is fully reversible; sudden maximal negative symptoms or persistent deficit suggests vascular disease.
  • Do not image solely for family reassurance when history and examination meet a primary headache pattern; MRI is preferred when a non-emergency structural question exists.
  • For adolescents, treat acute migraine early with an age-appropriate NSAID or paracetamol and consider a nasal triptan through the NICE pathway; avoid opioids.

Aetiology

01

Primary migraine biology

Genetic susceptibility alters trigeminovascular signalling, sensory processing and brain excitability, producing episodic headache with nausea, photophobia or aura.

02

Tension-type headache

Bilateral pressing pain relates to central pain processing, sleep, stress and musculoskeletal factors without migraine autonomic features or structural disease.

03

Raised intracranial pressure

Tumour, hydrocephalus, venous thrombosis, idiopathic intracranial hypertension or shunt failure increases pressure and threatens vision or brainstem function.

04

Secondary systemic cause

Meningitis, viral illness, hypertension, carbon monoxide, medicines, sleep apnoea and ocular disease can produce headache through distinct mechanisms.

Pathophysiology

  1. 1
    Trigeminal activation

    Meningeal trigeminal afferents release vasoactive peptides and transmit pain through brainstem and thalamic pathways during migraine.

  2. 2
    Cortical spreading depolarisation

    A slowly propagating wave of altered cortical activity can generate reversible visual, sensory or language aura before headache.

  3. 3
    Pressure volume constraint

    Within the fixed skull, expanding tissue, cerebrospinal fluid or blood eventually overwhelms compensation and reduces cerebral perfusion.

  4. 4
    Optic nerve transmission

    Raised cerebrospinal fluid pressure surrounds the optic nerve, causing disc swelling, transient visual obscurations and eventual visual loss.

Clinical features and red flags

Childhood migraine

Episodic disabling headache with nausea, light or sound sensitivity, pallor and desire to sleep may be bilateral and shorter than adult attacks.

Typical visual aura

Positive zigzags or scintillation develop gradually, spread across vision and resolve within 5–60 minutes before or during headache.

Raised-pressure pattern

Progressive waking or morning pain, vomiting, Valsalva worsening, diplopia, papilloedema or ataxia indicates urgent structural assessment.

Posterior fossa clue

New imbalance, abnormal head posture, squint, impaired upgaze or recurrent unexplained vomiting may precede a clear headache description.

Meningitic headache

Fever, neck stiffness, photophobia, non-blanching rash or altered interaction requires immediate infection treatment and investigation.

Red flags requiring action

  • For a child under 12, headache waking them, present on waking, progressively worsening or triggered by cough, sneeze or bending needs same-day neurological assessment under NICE.
  • Headache with vomiting, ataxia, change in consciousness, marked lethargy, fever with meningism or recent head injury also needs immediate assessment in children under 12.
  • Papilloedema, new squint, failure of upward gaze, abnormal head posture or rapidly increasing head circumference raises intracranial pressure or a posterior fossa lesion.

Investigations

  1. 01
    First-line neurological and fundal examinationFirst stepFirst line
    Why
    Identify focal deficit, papilloedema, cranial nerve palsy, ataxia or another secondary-headache sign.
    Interpretation and limitations
    Any abnormality accelerates imaging; normal findings support but do not override a strongly progressive red-flag history.
  2. 02
    Age-appropriate blood pressure
    Why
    Detect severe hypertension as a treatable cause of headache or visual symptoms.
    Interpretation and limitations
    Confirm with the correct cuff and centile-based interpretation while urgent symptoms receive same-day assessment.
  3. 03
    Headache diary
    Why
    Quantify frequency, duration, disability, triggers, acute medicine use and menstrual association.
    Interpretation and limitations
    Use it to refine primary-headache management, never to postpone investigation of progression or neurological signs.
  4. 04
    Urgent CT or MRI
    Why
    Detect haemorrhage, hydrocephalus, tumour, infection complication or venous disease when secondary pathology is suspected.
    Interpretation and limitations
    CT prioritises speed in instability; MRI offers superior detail for stable structural evaluation and posterior fossa disease.

Differential diagnosis

01

Migraine

Episodic moderate or severe headache with nausea, photophobia, phonophobia and activity avoidance may be bilateral and shorter in children.

02

Brain tumour or hydrocephalus

Progression, morning or waking symptoms, vomiting, ataxia, cranial nerve findings or papilloedema suggests an expanding intracranial process.

03

Meningitis or encephalitis

Fever, neck stiffness, rash, photophobia, seizure or altered behaviour requires immediate antimicrobial assessment rather than migraine treatment.

04

Medication-overuse headache

Frequent use of analgesics or triptans can sustain near-daily headache and requires supported withdrawal after excluding dangerous secondary disease.

05

Hypertension or ocular disease

Raised blood pressure, visual strain, acute glaucoma or inflammatory eye disease may present with headache and examination-specific clues.

Management

01TriageAct on immediate red flagsFirst stepHeadache accompanies neurological, infective, pressure or vascular warning features.+
  1. 1Use ABCDE and assess consciousness, pupils, blood pressure, glucose, fever and rash.
  2. 2Obtain urgent paediatric, neurological or neurosurgical help and select immediate imaging.
  3. 3Treat suspected meningitis, encephalitis, hypertension or other cause without unsafe lumbar puncture delay.
02DiagnoseMake a positive primary diagnosisHistory is recurrent and examination shows no secondary warning feature.+
  1. 1Classify migraine, aura and tension features using age-appropriate descriptions and disability.
  2. 2Review sleep, meals, hydration, caffeine, menstruation, stress and acute medicine frequency.
  3. 3Explain why imaging is unnecessary when a clear primary phenotype and normal examination agree.

Complications

01

Visual loss

Untreated intracranial hypertension can cause optic atrophy and irreversible field loss despite headache fluctuating or improving.

02

Herniation and brain injury

Rapid pressure escalation can impair consciousness, pupils, breathing and cerebral perfusion, leading to permanent neurological injury or death.

03

Migraine disability

Frequent attacks disrupt school, sleep, sport, mood and family function even when imaging and neurological examination are normal.

04

Medication overuse

Repeated short-acting analgesic or triptan exposure increases headache frequency and complicates assessment of the underlying primary disorder.

Monitoring and follow-up

  • Record monthly headache and acute-medicine days, duration, school absence and functional recovery.
  • Repeat neurological examination, fundoscopy and blood pressure when pattern or severity changes.
  • Escalate immediately for morning vomiting, visual obscuration, new squint, imbalance, seizure or altered behaviour.
  • Review sleep, hydration, meals, exercise, stress and menstrual association without implying symptoms are imagined.
  • During preventive therapy record a baseline and review response after an adequate trial alongside mood, cognition, pulse, blood pressure or weight as medicine-specific.
  • Check for analgesic or triptan overuse and support withdrawal with a clear alternative acute plan.

Special situations

Children show rather than tell

Stopping play, seeking darkness, pallor or sleep may communicate migraine more reliably than adult-style pain adjectives.

Morning vomiting is neurological

Recurrent unexplained early vomiting with imbalance or ocular change can be a posterior fossa presentation before headache is volunteered.

Fundoscopy needs competence

A note that discs were not seen is not equivalent to a normal fundal examination when pressure is plausible.

Aura has evolution

Gradual spread of positive reversible symptoms supports migraine; abrupt maximal loss of function requires vascular assessment.

Imaging can cause harm

Scanning a clear primary headache solely for reassurance risks sedation, radiation or incidental findings without improving care.

Common pitfalls

  1. 01

    Calling recurrent vomiting gastrointestinal without checking gait and eyes.

  2. 02

    Assuming a family migraine history overrides new red flags.

  3. 03

    Omitting blood pressure and fundoscopy from recurrent-headache assessment.

  4. 04

    Performing lumbar puncture before excluding dangerous raised pressure.

  5. 05

    Using opioids for childhood migraine.

  6. 06

    Allowing frequent analgesic use to perpetuate headache.

  7. 07

    Waiting for a headache diary before referring urgent symptoms.

A headache diary records frequency, duration, disability, menstruation, sleep, hydration, meals and medicines, but should not delay red-flag investigation.
  • Preventive treatment is considered when attacks are frequent or disabling after lifestyle and acute treatment are optimised, with shared discussion of off-label paediatric evidence.
  • Give explicit return advice for progression, morning vomiting, visual change, squint, imbalance, seizure, fever, rash or altered behaviour.
  • Thunderclap onset, focal weakness, seizure or neck pain after trauma suggests haemorrhage, arterial dissection, venous thrombosis or stroke.
  • Persistent headache in an immunocompromised child, a child with cancer or a child with a cerebrospinal fluid shunt has a lower threshold for urgent imaging and specialist input.
  • Hypertension must be measured with an appropriate cuff because headache and visual change may be the presenting features of severe paediatric blood-pressure elevation.
    • 05
    Lumbar puncture after safety assessment
    Why
    Measure opening pressure or analyse cerebrospinal fluid when infection or intracranial hypertension remains possible.
    Interpretation and limitations
    Defer when reduced consciousness, focal signs, papilloedema or imaging concern creates herniation risk; treat infection first when needed.
    03Acute careTreat migraine earlyA disabling migraine attack begins without secondary-headache features.+
    1. 1Give an age-appropriate NSAID or paracetamol early with quiet rest and fluid.
    2. 2For young people aged 12 and over, consider a nasal triptan and antiemetic through the NICE pathway.
    3. 3Avoid opioids and set monthly medicine-day limits to reduce overuse.
    04PreventionReduce recurrent disabilityAttacks remain frequent or disabling despite effective acute treatment and routine measures.+
    1. 1Use a diary to agree measurable school, activity and headache goals.
    2. 2Discuss specialist preventive treatment with comorbidity, adverse-effect and reproductive review.
    3. 3Reassess diagnosis and repeat neurological and fundal examination if the pattern changes.
    Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
    First-line acute analgesic option when there is no contraindication and the child can tolerate oral treatment.

    Ibuprofen

    For an acute migraine in children, use the age-appropriate oral BNFc regimen, commonly 10 mg/kg as a single early dose, maximum 400 mg per dose, with repeat frequency limited by age and product instructions.

    Avoid or seek advice with dehydration, renal disease, gastrointestinal bleeding, NSAID-sensitive asthma or varicella; frequent use can cause medication-overuse headache.

    Alternative acute treatment when NSAIDs are unsuitable or as the selected first analgesic in a younger child.

    Paracetamol

    Use an age- or weight-appropriate oral dose, commonly 15 mg/kg early in the attack, maximum 1 g per dose and no more than four doses in 24 hours, checking all combination products.

    Check formulation strength, body weight, liver disease, malnutrition and previous doses; overdose is dangerous and repeated use can sustain medication-overuse headache.

    Migraine-specific acute therapy when simple analgesia is insufficient, especially when nausea makes oral absorption unreliable.

    Nasal sumatriptan

    For a young person aged 12–17 years, NICE advises considering a nasal triptan; a common specialist regimen is 10 mg into one nostril at onset, with one repeat after at least 2 hours if prescribed, maximum two doses in 24 hours.

    Confirm migraine rather than vascular or pressure red flags; avoid in uncontrolled hypertension and significant vascular disease, review serotonergic interactions and monitor total triptan-use days.