Synopsis
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.
- 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.
- 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.
Key red flags
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.
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.
Investigation priorities
Identify focal deficit, papilloedema, cranial nerve palsy, ataxia or another secondary-headache sign.
Management branches
Headache accompanies neurological, infective, pressure or vascular warning features.
- Use ABCDE and assess consciousness, pupils, blood pressure, glucose, fever and rash.
- Obtain urgent paediatric, neurological or neurosurgical help and select immediate imaging.
- Treat suspected meningitis, encephalitis, hypertension or other cause without unsafe lumbar puncture delay.
Attacks remain frequent or disabling despite effective acute treatment and routine measures.
- Use a diary to agree measurable school, activity and headache goals.
- Discuss specialist preventive treatment with comorbidity, adverse-effect and reproductive review.
- Reassess diagnosis and repeat neurological and fundal examination if the pattern changes.