Headache Program Referral Guidelines

Although headaches are common in children, recurrent or frequent headaches that interfere with daily life are a concern. The Headache Program is a specialized clinic within the Division of Neurology that evaluates and treats more than 2,000 patients annually. The clinic helps children and adolescents with chronic, debilitating head pain, headaches and migraines. We work to identify the cause and find an effective way to help children manage their headaches. Members of our Headache Program team belong to the American Headache Society and work closely with the National Institutes of Health to meet the special needs of patients and their families with headache disorders.

How should I initially evaluate and manage my patient?

Ask about common symptoms seen in primary headaches

Tension headaches are diffuse, non-throbbing, mild to moderate severity headaches without significant worsening with activity, light or sound sensitivity or nausea
Migraine headaches are bifrontal or unilateral moderate to severe intensity headaches associated with a throbbing quality, worsening with activity, light or sound sensitivity, nausea and/or vomiting.
Migraine aura may occur before or during headaches lasting 5-60 minutes and include sensations of visual changes (dark or bright spots or lines), sensory changes (tingling, numbness) or speech changes

Consider other common causes of headache

Sinus headache
Post traumatic/concussive headache
Allergic rhinitis
Ophthalmologic problems
Depression

Instruct family on basic first line treatment for headaches

Lifestyle modification for prevention of headaches

Hydration – goal ounces per day = weight in pounds to a max of 100 oz per day, none with caffeine or artificial sweeteners
Exercise at least five days per week for 30 minutes
Sleep per AAP guidelines with no more than two hours of variability in sleep or wake timing
Eat three healthy well balanced meals per day

Abortive therapy when child gets a headache

Ibuprofen 10 mg/kg per dose, max 600mg/dose up to three days per week
8-12 oz. fluid bolus with medication, sports drinks preferable in those without contraindications (obesity, diabetes)
Triptans may be considered up to twice weekly if no contraindication

Preventative therapy may be considered in those with frequent headaches

Brain imaging studies are suggested for patients who have

Headaches for less than 6 months duration not responding to lifestyle changes and first line treatment (ibuprofen, triptans, cyproheptadine),
Headaches associated with abnormal neurologic exam findings, especially papilledema, nystagmus, gait or motor changes
Absent family history of headache
Headaches associated with substantial confusion or emesis
Headaches that awaken a child from sleep repeatedly
A family history or disorders that predispose child to central nervous system lesions such as brain tumors or cerebral aneurysms

Specific testing for children with other system complaints, including arthralgias, rash, sleep complaints

Patients with recurrent headache and a normal neurologic exam generally do not require additional testing

When should I refer my patient?

Providers may consider initiating referral to child neurology or the Emergency Department

If the patient has a new severe headache of acute onset, headache with focal neurologic deficit or papilledema, they should be referred to the Emergency Department for neuroimaging
If the patient has a recurrent headache that is not responding to standard medical treatment, including lifestyle modification and acute abortive treatment.

How can I refer my patient?

What can my patient expect from a visit to Children's National Hospital?

The specialist will take a detailed history of headaches, past medical and family history and conduct a focused medical examination.
Providers may instruct families to bring the following to the evaluation:
- A headache calendar for at least one month including dates of headaches, location, severity, associated symptoms, time at onset and resolution, activities preceding headaches including diet and treatment provided.
- A complete list of medications used for headache treatment including doses and frequency of use. Include any abortive or preventative medications used.
- Copies of testing done including other referrals, labs, imaging films/CDs (not just reports) and any other additional information.