Headaches in children under 12

Headaches are common in children with up to 70% of school age children experiencing a headache at least once a year, 40% of 7 year olds will have chronic recurrent headache this figure rises to 70% or more by the age of 15. Up to puberty headaches are more common in boys but after puberty the prevalence switches to female predominant.

The assessment of headache in children is very similar to that of the adult, however the causes for the headache have a different spectrum. The concerned parent can be a factor with worry about serious underlying pathology.

History and examination are key factors in determining the aetiology and deciding on the management both immediately and in the medium term. The history establishes the pattern of the headache, whereas examination is aimed at ruling out a secondary cause.

At first presentation the history should include

  • Duration of headache history
  • Duration of each episode
  • Severity of pain (consider using a “pain-face” rating scale 3-10 and 8)
  • Frequency of occurrence
  • Site
  • Pattern (time of day, activity, only on school days etc.)
  • Stimuli (hobbies, activity, diet, video games)
  • Aura/warning
  • Associated symptoms
  • Psychological well being (friends, bullying, progress in school, home issues)

The history may guide the initial examination, however the GP should consider:-

  • Temperature and pulse
  • Blood pressure
  • Level of alertness/interaction
  • Evidence of viral illness
  • Assessment of meningeal irritation
  • Examination and palpation of head for trauma
  • Appropriate neurological examination – including fundoscopy
  • Examination of the skin for rashes or vascular malformation

A careful neurological examination focusing on mental state, coordination, deep tendon reflexes, sensory, motor, eye movement and fundoscopic examination, can exclude a brain tumour in 98% of cases (The Childhood Brain Tumour Consortium, 1991)

Red flags

  • Short history – especially if first headache or worst ever
  • Recurrent headaches described as severe for 2 weeks or more
  • Change in character of headache – particularly over a short period
  • Acceleration in frequency/intensity
  • Waking with a headache, vomiting in the mornings, worse with cough or stooping/squatting
  • Under 3 yrs old
  • History of systemic illness
  • Confusion, reduction in responsiveness, abrupt personality change, fever or seizures
  • Consistency of location of recurrent headaches

The evaluation of chronic headache

Once the initial examination has ruled out an immediate serious condition the medium term investigation and management can take place. The GP may consider routine blood tests, however these are unlikely to aid with the diagnosis. It may be helpful to supply the child/parents with a headache diary and appropriate visual pain scale and arrange follow up.

Download a headache diary

Visual pain scale up to 8 years old

Visual pain scale 7 years +



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