Pediatrics (System-Integrated)

Pediatric headache: red flags and workup

Clinical Overview and When to Suspect Serious Pediatric Headache

— Primary headache (migraine, tension, TAC) accounts for >90% of pediatric headache visits

— Secondary causes of concern: brain tumor, idiopathic intracranial hypertension (IIH), CNS infection, hemorrhage, vascular malformation, hydrocephalus, CO poisoning, hypertensive emergency, posterior fossa lesion

— Brain tumor prevalence in children with isolated headache and normal neuro exam is <1%; with any neurologic abnormality, risk rises sharply

— Systemic: fever, weight loss, immunocompromise, malignancy history

— Neurologic: focal deficit, AMS, seizure, ataxia, papilledema, cranial nerve palsy (esp. CN VI)

— Onset: thunderclap (max in <1 min) → SAH until proven otherwise

— Older/younger extremes: age <6, especially preverbal children

— Pattern: progressive worsening over weeks; new headache type; positional (worse supine/with Valsalva); nocturnal awakening or early-morning headache with vomiting

— Papilledema or visual changes

— Precipitated by exertion/Valsalva

— Pregnancy/postpartum (adolescents)

Headache is common in children: by age 15, ~75% have had a significant headache; ~10% have recurrent migraine. The Step 3 task is distinguishing benign primary headache (migraine, tension-type) from secondary headache signaling intracranial pathology.

Epidemiologic priors

When to immediately suspect secondary headache (red flags — "SNOOP4" pediatric adaptation)

Step 3 management: A child with chronic, episodic, throbbing headache with photophobia, normal growth, normal exam, and family history of migraine does not need neuroimaging — diagnose migraine clinically and treat. Imaging is driven by red flags, not parental anxiety.

Board pearl: Occipital headache in a child is a red flag — far more often associated with posterior fossa tumors than in adults. Lower threshold for MRI.

Presentation Patterns and Key History

— Onset & tempo: acute (single severe event) vs acute-recurrent (migraine) vs chronic-progressive (tumor, IIH) vs chronic-non-progressive (tension, chronic migraine)

— Location: bilateral frontotemporal in young children is typical for migraine (unilateral pattern emerges in adolescence); occipital = red flag

— Quality: throbbing/pulsatile (migraine); band-like pressure (tension); stabbing (TAC)

— Duration: pediatric migraine can be as short as 2 hours (vs ≥4 hours in adults — ICHD-3 pediatric criterion)

— Associated symptoms: nausea/vomiting, photophobia, phonophobia, aura, abdominal pain (abdominal migraine), vertigo

— Triggers: sleep deprivation, skipped meals, dehydration, menses, screen time, stress, specific foods

— Relief: dark quiet room and sleep (migraine); persists with rest (concerning)

— Migraine without aura: ≥5 attacks, 2–72 h, ≥2 of (bilateral/unilateral, pulsating, mod-severe, worsened by activity), plus nausea or photo+phonophobia

— Tension-type: bilateral, pressing, mild-moderate, no nausea

— Cluster (rare in kids): unilateral periorbital, autonomic features (lacrimation, ptosis, miosis)

— Medication-overuse headache: >15 days/month with analgesic use ≥15 days (or triptan ≥10 days)

— School attendance and PedMIDAS disability score

— Sleep hygiene, caffeine, hydration

— Trauma (consider abusive head trauma in young child)

— VP shunt? Sickle cell? Coagulopathy? Recent LP?

— CO exposure: whole family with headaches, worse in winter, faulty furnace — classic vignette

Take a structured headache history — the diagnosis is 90% historical:

Pattern recognition

Critical history to elicit

Key distinction: Morning headache with vomiting that relieves the headache in a child = think increased ICP (tumor, hydrocephalus), not gastroenteritis. Mandatory neuroimaging.

Physical Exam Findings and Neurologic Assessment

— Hypertension: malignant HTN, pheochromocytoma, coarctation, renal disease — check BP in all 4 extremities if HTN found

— Fever + headache + neck stiffness → meningitis pathway

— Bradycardia + HTN + irregular respirations = Cushing triad → impending herniation

— Plot height, weight, head circumference (<3 yo); macrocephaly or crossing percentiles suggests hydrocephalus or mass

— Short stature + headache → craniopharyngioma (suprasellar) until ruled out

— Precocious/delayed puberty → hypothalamic-pituitary lesion

— ≥6 café-au-lait macules → NF1 (optic glioma)

— Ash-leaf spots, shagreen patch → tuberous sclerosis

— Port-wine stain V1 distribution → Sturge-Weber

— Sinus tenderness, dental exam, TMJ palpation

— Bruits over orbits/cranium → AVM

— Nuchal rigidity, Kernig/Brudzinski

— Fundoscopy for papilledema (mandatory; if uncooperative, get formal ophtho)

— Visual acuity, visual fields, pupillary exam

— Cranial nerves: CN VI palsy (false localizing — elevated ICP); CN III (uncal herniation); facial asymmetry

— Cerebellar testing: finger-nose, heel-shin, tandem gait, Romberg — posterior fossa tumors classically present with ataxia

— DTRs, strength, sensory; upgoing toes = UMN

— Mental status, speech

Vital signs first

Growth and development

Skin exam — neurocutaneous syndromes

Head and neck

Neurologic exam — the high-yield core

CCS pearl: On a CCS case of pediatric headache, always order fundoscopic exam, neuro exam, and BP before deciding on imaging. Documenting a normal exam protects against over-imaging; an abnormal exam justifies MRI and admission.

Board pearl: Head tilt in a child with headache may indicate posterior fossa tumor (compensating for trochlear palsy or tonsillar herniation) — not just torticollis.

Diagnostic Workup — Initial Labs and First-Line Imaging Decisions

— No imaging needed if: recurrent headaches with stable pattern, normal neuro exam, normal growth, no red flags, fits primary headache criteria

— AAN/Child Neurology Society guideline: routine neuroimaging is not indicated in children with recurrent headaches and normal exam

— CBC, BMP, ESR/CRP if systemic features

— TSH if fatigue/weight changes

— Carboxyhemoglobin if CO exposure suspected (whole-family headaches, winter)

— Pregnancy test in adolescent females before imaging/medication

— Toxicology if AMS

— Blood pressure (don't forget)

— MRI brain (with and without contrast) is the preferred modality in children — no ionizing radiation, superior for posterior fossa, white matter, tumors, demyelination

— CT head (non-contrast) is appropriate for acute emergencies: thunderclap headache (SAH), trauma, suspected herniation, when MRI not immediately available

— Add MRV if suspecting cerebral venous sinus thrombosis (papilledema, OCP use, dehydration, hypercoagulable)

— Add MRA for vascular malformation, dissection

— Thunderclap headache

— Focal neuro deficit, seizure, AMS

— Papilledema

— Severe trauma

— Suspected shunt malfunction (VP shunt series + CT)

The dominant Step 3 decision: do I image, and if so, what?

Initial labs (selective, not routine)

Imaging modality choice

Indications for emergent imaging (CT in ED → then MRI)

Step 3 management: A 12-year-old with 2 years of episodic throbbing headaches, normal exam, normal growth, mother has migraine → clinical diagnosis of migraine; no imaging, no labs. Initiate lifestyle counseling and abortive therapy. Ordering MRI here is a wrong-answer trap.

Board pearl: EEG is NOT indicated in routine headache workup, even with aura — aura is a clinical migraine feature, not seizure. EEG only if paroxysmal events suggest epilepsy.

Diagnostic Workup — Advanced and Confirmatory Studies

— Suspected CNS infection: meningitis, encephalitis (after CT if focal deficits/papilledema/immunocompromise)

— Suspected SAH with negative CT (within 6 h CT sensitivity ~98%; beyond 6 h, LP for xanthochromia)

— Suspected IIH (pseudotumor cerebri): measure opening pressure in lateral decubitus position with legs extended

— Normal pediatric OP: ≤25 cm H₂O (≤28 if sedated/obese) per updated criteria

— IIH: elevated OP + normal CSF composition + normal neuroimaging (or empty sella, transverse sinus stenosis)

— Always image first if papilledema, focal deficit, or AMS to exclude mass

— MRV for venous sinus thrombosis (key mimic of IIH)

— MRA for AVM, aneurysm, dissection, moyamoya (sickle cell with headache)

— Pituitary protocol if endocrine dysfunction or visual field defect

— Spine MRI if Chiari I suspected (cough/exertion headache, occipital)

— Ophthalmology: formal visual field testing in IIH (track for progressive vision loss)

— Sleep study if morning headache + snoring → OSA

— Echocardiogram if exertional headache + cardiac murmur (consider coarctation)

— Genetic/metabolic testing if developmental regression, episodic with vomiting (mitochondrial — MELAS)

— Frequency, duration, severity, triggers, meds, menstrual cycle

— Establishes baseline and tracks response to therapy

Lumbar puncture — when and how

MRI with specific protocols

Specialized testing

Headache diary — the most underused diagnostic tool

Key distinction: IIH vs cerebral venous sinus thrombosis — both present with headache, papilledema, elevated OP, and normal CSF. MRV is mandatory before labeling a patient with IIH. Missing CVST risks venous infarct and death.

Board pearl: In a child with sickle cell disease and new headache, get MRI/MRA urgently — risk of silent infarct, overt stroke, and moyamoya. Don't dismiss as migraine.

Risk Stratification and Management Logic

— Tier 1 — Emergency (ED, neurosurgery/neurology stat): thunderclap, focal deficit, AMS, papilledema with new headache, suspected herniation, shunt malfunction, meningitis features, status migrainosus with dehydration

— Tier 2 — Urgent outpatient (neurology within days-weeks): progressive headache, abnormal but stable neuro exam, suspected IIH stable, atypical features

— Tier 3 — Primary care management: classic migraine or tension-type with normal exam, stable pattern

— PedMIDAS score guides aggressiveness:

— 0–10: little/no disability — lifestyle + abortive only

— 11–30: mild — abortive + consider prophylaxis

— 31–50: moderate — prophylaxis indicated

— >50: severe — prophylaxis + multimodal (behavioral, neuro referral)

— Sleep: consistent schedule, age-appropriate duration

— Meals: regular, no skipping; adequate protein

— Activity: aerobic exercise 3–5×/week

— Relaxation/stress management; consider CBT

— Trigger identification via diary; hydration (≥40–60 oz/day in adolescents)

— Limit caffeine, screens before bed, medication overuse

Triage framework after history/exam/imaging

Migraine severity and disability assessment

Lifestyle foundation (the "SMART" plan; evidence-based first step)

Step 3 management: Lifestyle modification + headache diary should be the first prescription for nearly every pediatric primary headache. Pharmacotherapy without lifestyle counseling is incomplete and a frequent wrong-answer pattern.

CCS pearl: Order "headache diary," "school accommodations letter," and "follow-up in 4–6 weeks" alongside any medication. Step 3 rewards longitudinal, ambulatory thinking — not just drug names.

Board pearl: Treat medication-overuse headache by withdrawing the offending analgesic — adding another abortive worsens the cycle.

Pharmacotherapy — Abortive (First-Line) Therapy

— Treat early in attack (within 1 hour), at adequate dose

— Limit use to <2–3 days/week to prevent medication-overuse headache

— Provide rescue plan and antiemetic

— Ibuprofen 10 mg/kg PO (max 600–800 mg) — best-evidenced first agent; superior to acetaminophen in trials

— Acetaminophen 15 mg/kg PO (max 1000 mg) — alternative, especially if NSAID contraindicated

— Take at headache onset with fluids; rest in dark, quiet room

— FDA-approved in pediatrics:

— Almotriptan ≥12 yr

— Rizatriptan ≥6 yr

— Sumatriptan/naproxen combo ≥12 yr

— Zolmitriptan nasal ≥12 yr

— Nasal/ODT useful if vomiting prominent

— Contraindications: hemiplegic/basilar migraine, vascular disease, uncontrolled HTN, ergot/MAOI use

— Counsel on serotonin syndrome risk with SSRIs (small but real)

— Ondansetron 0.15 mg/kg (max 8 mg) — first-line; check QTc if other risks

— Prochlorperazine or metoclopramide IV in ED for severe attacks — also have intrinsic anti-migraine effect; pretreat with diphenhydramine for dystonia

— IV fluids (NS bolus 10–20 mL/kg)

— IV ketorolac 0.5 mg/kg (max 30 mg)

— IV prochlorperazine 0.15 mg/kg + diphenhydramine

— IV magnesium sulfate 25–50 mg/kg

— IV valproate or dihydroergotamine if refractory (inpatient)

— Opioids and butalbital — high MOH risk, no role

— Aspirin in <16 yr (Reye syndrome)

Abortive therapy principles

First-line abortives in children/adolescents

Triptans (for moderate-severe migraine or NSAID failure)

Antiemetics (often the difference-maker)

Status migrainosus (>72 h) ED protocol

Avoid

Board pearl: Best abortive for a 10-year-old with moderate migraine = ibuprofen 10 mg/kg PO at onset + ondansetron + dark room. Triptan is added if NSAID fails. Don't jump to opioids — ever.

Pharmacotherapy — Prophylaxis and Non-Pharmacologic Therapy

— ≥4 disabling headaches/month, PedMIDAS >30, or abortive overuse

— Hemiplegic, basilar, or prolonged-aura migraine

— The 2017 CHAMP trial showed amitriptyline and topiramate were no better than placebo in pediatric migraine prophylaxis (all groups improved ~50%)

— Implication: CBT, lifestyle, and placebo response are powerful; medication choice driven by side-effect profile and comorbidity

— Topiramate (FDA-approved ≥12 yr): start 15–25 mg qHS, titrate to 1–2 mg/kg/day. SE: cognitive slowing, paresthesias, weight loss, kidney stones, oligohydrosis, teratogen (cleft lip/palate — counsel adolescent females, contraception)

— Amitriptyline: 0.25–1 mg/kg qHS. SE: sedation, weight gain, QTc prolongation (baseline ECG), anticholinergic

— Propranolol: 1–2 mg/kg/day divided. Avoid in asthma, depression, diabetes

— Cyproheptadine: useful in young children (<10 yr); SE: sedation, appetite increase

— Riboflavin (vit B2) 400 mg/day, magnesium 400 mg/day, CoQ10 — favorable safety, modest evidence

— CBT has the strongest evidence for chronic pediatric migraine — combine with amitriptyline for synergy (Powers et al. JAMA 2013)

— Biofeedback, relaxation training, mindfulness

— Menstrual migraine: NSAID prophylaxis around menses; consider continuous OCP (avoid estrogen if migraine with aura — stroke risk)

— Chronic migraine: address sleep, mood, MOH first

When to start prophylaxis

Evidence note — CHAMP trial caveat

Common prophylactic agents

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) — adult-approved; pediatric trials emerging; not first-line in children

Behavioral therapy

Special situations

Step 3 management: For a 14-year-old with frequent migraines, overweight, with insomnia → amitriptyline + CBT is a strong combination. For the same patient who is underweight → topiramate (weight loss can be desirable side effect). Match drug to comorbidity.

Special Populations — Renal, Hepatic, and Comorbid Conditions

— NSAIDs (ibuprofen, ketorolac, naproxen) — avoid in CKD, dehydration, single kidney; risk of AKI and worsening proteinuria

— Adjust topiramate in renal impairment (50% dose if CrCl <70); increases risk of nephrolithiasis — ensure hydration

— Triptans: generally safe but reduce dose with severe renal disease

— Acetaminophen — safe in moderate doses, but avoid in active hepatitis; max 75 mg/kg/day pediatric, max 4 g/day adult

— Valproate — hepatotoxic; contraindicated in <2 yr (fatal hepatic failure risk) and in mitochondrial disease (POLG mutations)

— Amitriptyline metabolized hepatically — reduce dose

— Triptans contraindicated in known CAD, uncontrolled HTN, Wolff-Parkinson-White

— Amitriptyline: baseline ECG; avoid if QTc >450 ms or family hx sudden death

— Propranolol: contraindicated in asthma, AV block, decompensated HF

— Obesity is the strongest modifiable risk factor for IIH in adolescents

— Weight loss is first-line for IIH; pharmacotherapy = acetazolamide (start 25 mg/kg/day, max 100 mg/kg/day or 2 g/day); monitor electrolytes, bicarbonate, kidney stones

— Surgical: optic nerve sheath fenestration or CSF shunting if vision threatened

— Headache → urgent MRI/MRA; risk of overt stroke, silent infarct, moyamoya

— Transcranial Doppler screening per protocol

— Optimize hydroxyurea, transfusion strategy

— Anxiety/depression coexist in 30–50% of chronic migraineurs

— Treat both; SSRIs + triptan: monitor for serotonin syndrome (low absolute risk per FDA reanalysis but counsel)

Renal impairment

Hepatic impairment

Cardiovascular comorbidity

Obesity and IIH

Sickle cell disease

Psychiatric comorbidity

Board pearl: A teen with chronic daily headache, anxiety, school avoidance, and frequent ibuprofen use likely has medication-overuse headache + comorbid anxiety. Treatment = analgesic withdrawal + CBT + bridge prophylaxis, not another NSAID.

Special Populations — Age Extremes, Pregnancy, and Athletes

— Recurrent headache is uncommon and warrants lower imaging threshold

— Limited expressive ability — observe for behavioral correlates: holding head, photophobia (turns off lights), seeking quiet, vomiting

— Cyproheptadine often preferred for prophylaxis given safety

— Always consider abusive head trauma in young child with new headache and AMS or unexplained findings

— Establish menstrual relationship — pure menstrual migraine vs menstrually-related

— Migraine with aura is a contraindication to combined estrogen-containing contraceptives (ischemic stroke risk; WHO Category 4) — use progestin-only or non-hormonal

— Counsel on topiramate teratogenicity (cleft lip/palate, FGR) and valproate (NTD, IQ reduction — avoid in females of reproductive age)

— Pregnancy test before imaging and prescribing

— Acetaminophen = abortive of choice

— NSAIDs — avoid after 20 wk (oligohydramnios, premature ductal closure)

— Triptans (sumatriptan has most data) — use if needed; not first-line

— Prophylaxis: propranolol or low-dose amitriptyline if essential

— New severe headache in pregnant adolescent → rule out preeclampsia, CVST, PRES, pituitary apoplexy

— Post-concussive headache: most common somatic symptom after pediatric concussion

— Return-to-play: stepwise per CDC/Zurich consensus; no return while symptomatic

— Watch for second-impact syndrome — devastating cerebral edema with repeat injury before recovery

— Persistent post-traumatic headache (>4 weeks) → multidisciplinary clinic, vestibular therapy

Very young children (<6 years)

Adolescent females

Pregnancy (in adolescents)

Athletes and concussion

Step 3 management: For an adolescent athlete with concussion-related headache, the order set includes: physical and cognitive rest, return-to-learn plan, return-to-play protocol, ibuprofen short-term, follow-up in 1–2 weeks, school accommodation letter. Do not clear for sport while symptomatic.

Complications and Adverse Outcomes

— Chronification: episodic → chronic migraine (≥15 days/month for >3 months)

— Medication-overuse headache: iatrogenic, often missed

— School absenteeism, academic decline, social isolation

— Depression, anxiety, suicidality (screen with PHQ-A)

— Loss of family income (parental work absence)

— Brain tumor (medulloblastoma, ependymoma, pilocytic astrocytoma): hydrocephalus, herniation, vision loss, endocrine dysfunction (craniopharyngioma → panhypopituitarism, diabetes insipidus, growth failure)

— IIH: permanent vision loss is the feared outcome — track visual fields, not just acuity

— CVST: venous infarct, hemorrhage, seizure, death

— SAH/AVM rupture: rebleed, vasospasm, hydrocephalus

— Meningitis: sensorineural hearing loss (give dexamethasone before/with first antibiotic for Hib; benefit less clear for pneumococcus in children), seizures, cognitive impairment

— Shunt malfunction: rapid deterioration, death within hours if untreated

— Topiramate → metabolic acidosis, kidney stones, oligohydrosis (heat stroke risk — counsel especially summer athletes), word-finding difficulty

— Valproate → hepatotoxicity, pancreatitis, hyperammonemia, weight gain, PCOS, teratogenicity

— Amitriptyline → QTc, anticholinergic, overdose-lethality (counsel on storage; small pill count if depression risk)

— Triptan + SSRI/SNRI → serotonin syndrome (rare)

— Ergots → ergotism, vasospasm (avoid in children)

Complications of untreated or missed primary headache

Complications of secondary causes

Medication adverse effects (high-yield)

CCS pearl: When prescribing topiramate, order: baseline metabolic panel, hydration counseling, contraception counseling if female, follow-up at 4 weeks. Repeat BMP at 1 month to detect metabolic acidosis.

Board pearl: Vision loss in IIH is the catastrophic miss — serial visual fields (Humphrey) every 2–4 weeks initially, more often than acuity, drive management escalation.

When to Escalate — ED, Inpatient, ICU, and Consult Triggers

— Thunderclap headache (peak <1 min)

— New focal neurologic deficit

— Altered mental status, seizure

— Suspected meningitis (fever, neck stiffness, petechiae)

— Papilledema with new headache

— Suspected shunt malfunction

— Suspected CO poisoning (whole household)

— Status migrainosus with dehydration/intractable vomiting

— Atypical features, abnormal imaging

— Failure of 2 prophylactic agents at adequate dose/duration (8–12 weeks)

— Hemiplegic, basilar, or prolonged-aura migraine

— Suspected IIH, CVST, secondary headache syndromes

— Mass lesion, hydrocephalus, shunt malfunction

— SAH, large AVM, Chiari I with progressive symptoms

— IIH refractory to medical therapy with vision loss

— Any papilledema → urgent

— IIH follow-up for visual fields and OCT

— Herniation risk (Cushing triad, blown pupil, posturing)

— Status epilepticus

— Severe meningitis/encephalitis with cardiopulmonary instability

— Post-op craniotomy

— Status migrainosus failing ED therapy → admit for IV DHE protocol, IV valproate, hydration

— Bacterial meningitis (after appropriate workup and antibiotics in ED)

— New diagnosis of brain tumor for staging, steroids, neurosurgical planning

Immediate ED transfer

Neurology consult (urgent outpatient or inpatient)

Neurosurgery consult

Ophthalmology

PICU admission

Inpatient (non-ICU) admission

CCS pearl: For status migrainosus admission, order set: IV NS, IV ketorolac, IV prochlorperazine + diphenhydramine, IV magnesium, ondansetron PRN, dark room, neurology consult, MRI brain (if not already), DVT prophylaxis if adolescent immobile, transition to oral abortive before discharge with clinic follow-up in 1 week.

Key Differentials — Primary Headache Disorders

— ≥5 attacks, 2–72 h (pediatric), bilateral or unilateral, pulsating, mod-severe, worse with activity; nausea or photo/phonophobia

— Reversible visual/sensory/speech/motor symptoms developing over ≥5 min, lasting 5–60 min, followed by headache within 60 min

— Hemiplegic migraine — motor weakness; familial form linked to CACNA1A, ATP1A2, SCN1A

— Basilar-type (migraine with brainstem aura): vertigo, diplopia, ataxia, tinnitus — triptan contraindicated

— Bilateral, pressing/tightening, mild-moderate, not worsened by activity, no nausea

— Often related to stress, posture, screen use

— Cluster: severe unilateral orbital, 15–180 min, autonomic features (lacrimation, rhinorrhea, ptosis); high-flow O₂ + subQ sumatriptan

— Paroxysmal hemicrania: shorter attacks, responds to indomethacin (diagnostic)

— Cyclic vomiting syndrome: stereotyped episodes of intense vomiting with symptom-free intervals

— Abdominal migraine: midline abdominal pain ≥1 hr, anorexia/nausea/vomiting/pallor, no GI cause

— Benign paroxysmal vertigo of childhood: brief vertigo episodes, normal between

— Benign paroxysmal torticollis: head tilt episodes in infancy

— Most evolve into typical migraine in adolescence

— Headache daily and unremitting from a clearly remembered onset day, >3 months — often follows viral illness; difficult to treat

Migraine without aura

Migraine with aura

Tension-type headache

Trigeminal autonomic cephalalgias (rare in children)

Childhood periodic syndromes (migraine equivalents)

New daily persistent headache (NDPH)

Key distinction: Cyclic vomiting syndrome vs gastroenteritis — CVS has stereotyped, recurrent episodes with completely well intervals and strong family history of migraine. Treat with migraine prophylaxis (cyproheptadine, propranolol, amitriptyline) and abortive antiemetics, not just rehydration.

Key Differentials — Secondary and Dangerous Causes

— Brain tumors in children: posterior fossa dominance (medulloblastoma, pilocytic astrocytoma, ependymoma, brainstem glioma)

— Classic triad: morning headache, vomiting, ataxia

— Supratentorial: seizures, focal deficits, endocrine

— Craniopharyngioma: bitemporal hemianopia, short stature, DI

— Obese adolescent female; daily headache, transient visual obscurations, pulsatile tinnitus, papilledema, CN VI palsy

— Diagnose via MRI/MRV (rule out CVST/mass) + elevated OP on LP + normal CSF

— Tx: weight loss + acetazolamide; surgical if vision threatens

— Risk: OCP, dehydration, infection (mastoiditis), hypercoagulable, nephrotic, pregnancy

— Headache + papilledema + seizure/focal deficit; MRV diagnostic; tx anticoagulation

— Bacterial meningitis, viral encephalitis (HSV — temporal lobe), brain abscess, sinusitis with intracranial extension (Pott puffy tumor)

— SAH (AVM rupture more common in children than aneurysm)

— Arterial dissection (trauma, connective tissue disease)

— Moyamoya (sickle cell, NF1, Down syndrome) — TIA + headache

— Hypertensive emergency, PRES

— Concussion, post-traumatic headache, epidural/subdural hematoma

— Abusive head trauma in young children

— CO poisoning — family clustering, faulty heater, cherry-red skin (late); carboxyhemoglobin diagnostic; 100% O₂ ± hyperbaric

— Lead poisoning

— Caffeine withdrawal, medication overuse

— Sleep apnea, hypoxia

— Refractive error, eye strain (rarely sole cause; check anyway)

Intracranial mass

Idiopathic intracranial hypertension (pseudotumor cerebri)

Cerebral venous sinus thrombosis

Infection

Vascular

Trauma

Toxic/metabolic

Ophthalmologic

Board pearl: Family with multiple members having headache, nausea, and fatigue in winter → check carboxyhemoglobin. Classic missed diagnosis; reportable to public health/utility company.

Long-Term Plan, Discharge Planning, and Secondary Prevention

— Confirmed abortive plan: NSAID + antiemetic ± triptan with dosing instructions

— Rescue plan written: "If headache not better in 2 hours, take X; if vomiting prevents oral, use nasal/ODT triptan or ondansetron ODT"

— Initiate or adjust prophylaxis if frequency warrants

— Headache diary started (paper or app)

— Counsel on medication-overuse threshold: NSAIDs <15 days/month, triptans <10 days/month

— Sleep: age-based hours, consistent bed/wake time, no screens 1 h before bed

— Hydration: target volume in oz/day

— Meals: 3 + 2 snacks, no skipping, protein at breakfast

— Exercise: 30 min aerobic ≥3×/wk

— Caffeine cap: <1 serving/day; avoid energy drinks

— Stress reduction: identify CBT resource

— Permission to leave class with headache; access to quiet room

— Bathroom access, water access

— Sunglasses/hat indoors if photophobia

— Make-up work flexibility

— 504 plan if disability significant

— Routine pediatric immunizations

— Annual influenza

— HPV, meningococcal per ACIP

— Screen depression (PHQ-A), anxiety (GAD-7), sleep, ADHD

— Treat anemia, vitamin D deficiency if found

Discharge medication checklist (status migrainosus or ED visit)

Lifestyle prescription (written, specific)

School accommodation letter

Vaccinations and preventive care

Comorbidity management

Step 3 management: Discharge from ED for migraine = abortive + rescue plan + diary + lifestyle handout + school letter + PCP follow-up in 1–2 weeks + neurology referral if PedMIDAS >30. Missing any element is a common Step 3 wrong answer.

Board pearl: CBT has equal or greater efficacy than pharmacotherapy for chronic pediatric migraine — always offer/refer, not as last resort.

Follow-Up, Monitoring Parameters, and Family Counseling

— Primary headache, newly diagnosed: PCP in 4–6 weeks to review diary, response, side effects

— Prophylactic medication initiated: 4-week check for tolerability, 8–12 weeks for efficacy (adequate trial)

— Stable on therapy: every 3–6 months

— IIH: ophthalmology q2–4 wk initially for visual fields; neurology q1–3 mo

— Post-concussion: weekly until symptom-free, then RTP protocol

— Topiramate: BMP at baseline and 4 weeks (bicarbonate), weight, cognition, mood, hydration

— Valproate: LFTs, CBC, ammonia if symptomatic; pregnancy test; do not use in females of reproductive potential when alternatives exist

— Amitriptyline: baseline ECG (QTc), weight, suicidality screen

— Propranolol: HR, BP, exercise tolerance, mood; check glucose if diabetic

— Acetazolamide: BMP (bicarbonate, K), urinalysis (stones), CBC (rare aplastic anemia)

— After 6–12 months of good control, taper (do not abrupt-stop propranolol)

— Reassess; many adolescents will not need ongoing therapy

— Headaches are real, not malingering — validate

— Migraine is genetic; parents often share — normalize, share lifestyle measures family-wide

— Set realistic expectations: goal is 50% reduction in frequency/intensity, not zero headaches

— Avoid "reinforcing" sick role — minimize secondary gain, keep child in school where possible

— Adolescent → adult care: written summary, medication list, last MRI report

— School nurse communication for in-school abortive administration

Follow-up cadence

Monitoring parameters by drug

When to discontinue prophylaxis

Family education

Care transitions

CCS pearl: When advancing the clock on a CCS case, schedule PCP follow-up at 4 weeks after starting prophylaxis. Re-examine, review diary, check labs as relevant, adjust dose. Reassess at 8–12 weeks before declaring treatment failure.

Ethical, Legal, and Patient Safety Considerations

— Most pediatric headache decisions involve parents as legal decision-makers

— Adolescents capable of assent should be engaged; document

— Confidential care for adolescents: discuss substance use, contraception, mental health one-on-one (state laws vary; most allow confidential care for contraception, STI, mental health)

— Counsel on teratogenicity of topiramate and valproate with adolescent female and parent; document contraception discussion

— Suspected abusive head trauma (young child, retinal hemorrhages, subdural hematomas of varying ages, inconsistent history) → mandatory CPS report; admit child for safety while workup proceeds

— Suspected CO poisoning from a residence → notify public health/utility; do not return child to unsafe environment

— Avoid unnecessary CT (radiation, lifetime cancer risk in children is non-trivial); prefer MRI when imaging is needed

— Choosing Wisely: do not perform neuroimaging in children with recurrent headache and normal neuro exam — discuss with family; address anxiety with explanation, not imaging

— Amitriptyline overdose is potentially fatal — small dispense quantities if depression/suicidality risk

— Lock medications; counsel on accidental pediatric ingestion

— Avoid codeine/tramadol in children (FDA boxed warning — variable CYP2D6 metabolism, respiratory depression)

— Aspirin avoidance in children (Reye)

— ED → PCP handoff: ensure diagnosis, meds, follow-up communicated; printed discharge instructions in family's preferred language; teach-back confirmation

— Adolescent → adult provider transition: structured handoff document

— 504 plan for documented chronic headache disorder

— Avoid over-medicalization that reinforces school avoidance

Informed consent and adolescent autonomy

Mandatory reporting

Imaging stewardship

Medication safety

Transitions of care

School and disability

Step 3 management: A 15-year-old female started on topiramate must have (1) pregnancy test documented, (2) contraception counseling, (3) teratogenicity discussion with adolescent and parent, (4) plan for periodic pregnancy testing. Skipping any element is a board-style negligence trap.

High-Yield Associations and Rapid-Fire Clinical Facts

— Morning headache + vomiting + ataxia in child → posterior fossa tumor (medulloblastoma)

— Obese teen girl + papilledema + pulsatile tinnitus → IIH

— Whole family with winter headaches → CO poisoning

— Occipital headache worse with cough/Valsalva → Chiari I

— Short stature + bitemporal hemianopia + headache → craniopharyngioma

— Thunderclap headache → SAH

— Headache + seizure + OCP use → CVST

— Café-au-lait + headache + vision change → NF1 with optic pathway glioma

— Sickle cell + headache → stroke/moyamoya — image now

— Recurrent abdominal pain + family hx migraine → abdominal migraine

— Stereotyped vomiting episodes with wellness between → cyclic vomiting syndrome

— Pediatric migraine duration: 2–72 hours (vs adult 4–72)

— Bilateral frontotemporal location is common in young children

— Aura without headache can occur — diagnosis of exclusion

— Triptans approved: rizatriptan ≥6 yr; almotriptan, zolmitriptan nasal, sumatriptan/naproxen ≥12 yr

— Best evidence in pediatric acute: ibuprofen

— CHAMP trial: amitriptyline and topiramate = placebo (in trial population)

— Migraine with aura + combined OCP = stroke risk → avoid estrogen

— SNOOP4 for red flags

— SMART lifestyle plan

— POUND: Pulsatile, One-day duration, Unilateral, Nausea, Disabling = migraine

— IIH OP cutoff (pediatric, non-sedated, non-obese): >25 cm H₂O

— PedMIDAS >30 → consider prophylaxis

— Adequate prophylaxis trial: 8–12 weeks at target dose

— Medication-overuse thresholds: NSAID ≥15 d/mo, triptan ≥10 d/mo

Buzzwords → diagnosis

Pearls

Mnemonics

Numbers to know

Board pearl: When the stem mentions age <6, occipital location, awakening from sleep, or worsening over weeks, the answer involves MRI brain, not migraine therapy.

Board Question Stem Patterns

— 12-year-old, 2-year history episodic throbbing bilateral headache, photophobia, family hx migraine, normal exam → Answer: Diagnose migraine; ibuprofen at onset + lifestyle + diary; wrong: MRI, EEG, CT

— 8-year-old, 6 weeks worsening morning headache, vomiting, recent ataxic gait, head tilt → Answer: MRI brain with contrast; admit, neurosurgery consult; wrong: outpatient migraine treatment

— Obese 14-year-old female, daily headache, transient visual graying, papilledema, normal MRI → next step MRV (rule out CVST), then LP with OP; treat: weight loss + acetazolamide; monitor: visual fields

— Adolescent on OCP, dehydration after viral illness, headache + seizure, papilledema → MRV diagnostic, anticoagulate

— Multiple family members with headache, nausea, dizziness in winter, faulty furnace → carboxyhemoglobin, 100% O₂, evacuate home, notify utility

— Teen, 4-day refractory migraine, dehydrated, vomiting → ED: IVF + ketorolac + prochlorperazine/diphenhydramine + magnesium; admit if persists

— 16-year-old daily headache, ibuprofen daily for months → withdraw analgesic, bridge therapy, start prophylaxis + CBT

— Teen with migraine with aura asks about combined OCP → avoid estrogen-containing; offer progestin-only or non-hormonal (stroke risk)

— Female adolescent prescribed topiramate → ensure pregnancy test, contraception, teratogenicity discussion

— Always image (MRI/MRA), do not assume migraine

Pattern 1 — "Reassurance and migraine management"

Pattern 2 — "Posterior fossa tumor"

Pattern 3 — "IIH"

Pattern 4 — "CVST"

Pattern 5 — "Carbon monoxide"

Pattern 6 — "Status migrainosus"

Pattern 7 — "Medication-overuse headache"

Pattern 8 — "Aura + OCP"

Pattern 9 — "Teratogen counseling"

Pattern 10 — "Sickle cell + headache"

Step 3 management: Always pair the right diagnosis with the right next step + right follow-up interval + right counseling. Step 3 stems test the whole management arc, not just the diagnosis.

One-Line Recap

The Step 3 essence: In a child with headache, a careful history and neurologic exam stratify benign primary headache (treat with lifestyle + ibuprofen ± triptan, prophylaxis if PedMIDAS >30) from dangerous secondary headache (red flags: thunderclap, focal deficit, papilledema, morning emesis, age <6, occipital, progressive) which mandates urgent MRI and appropriate escalation.

Red-flag screen (SNOOP4) drives imaging — not parental anxiety, not headache severity alone; normal neuro exam + recurrent stable pattern = no imaging

First-line abortive = ibuprofen 10 mg/kg at onset + antiemetic; add triptan (rizatriptan ≥6 yr; sumatriptan/naproxen ≥12 yr) if NSAID inadequate; never opioids, never butalbital, never aspirin <16 yr

Prophylaxis for PedMIDAS >30 or ≥4 disabling HA/mo: choose drug by comorbidity (topiramate if obese; amitriptyline if insomnia; propranolol if anxiety without asthma); add CBT — best evidence base in pediatrics; allow 8–12 weeks for adequate trial

Don't miss: posterior fossa tumor (morning HA + ataxia), IIH (obese teen + papilledema; MRV before LP), CVST (OCP + dehydration + seizure), CO poisoning (clustered family symptoms), sickle cell stroke; counsel teratogenicity of topiramate/valproate and avoid estrogen-containing contraception in migraine with aura