Headache occurring in children under the age of 5 years may cause a high level of anxiety in both parents and medical professionals. Crucial to a consultation about this problem will be to actively seek out clues to sinister pathologies, and investigate or reassure as appropriate. Making a positive diagnosis of a primary headache disorder where one exists is also important; however, in young children, headache does not always conform to well-established diagnostic criteria. This short guide provides a practical overview using the scenario of a new referral to the outpatient clinic.
- Child, preschool
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Before the consultation
You have a few moments to look at the referral letter for your first clinic patient of the day. It begins ‘please see this 4-year-old boy who complains of headache.’ In preparing for the consultation, the following questions come to mind:
Is it a brain tumour?
This is a key question to consider, and is one that may be troubling the child's parents. If the headache is a symptom of a brain tumour, you will want to identify this as the likely cause and arrange urgent imaging. If not, you will need to feel confident that you have excluded a brain tumour so as to avoid unnecessary brain imaging and to be able to reassure the parents.
Up to two-thirds of children with a brain tumour will complain of headache, either as an initial symptom or at a later stage.1–,3 The incidence of brain tumours in preschool children is 3–4 per 100 000 per year,4 whereas, up to 20% of preschool children will complain of headache at some point.5 As at other ages of childhood and adolescence, the vast majority of young children with a headache will not have a brain tumour.
Brain tumours tend to be diagnosed later than other childhood cancers. Around one-fifth of children with headache due to brain tumours are first misdiagnosed by doctors as having primary headache.1 ,2 Studies looking at diagnostic delay in brain tumours show that children under 5 years old are diagnosed sooner than older children, however, this may relate to tumour grade, and the greater degree of parental concern with younger children.1
Is it possible to confidently rule out a tumour on the basis of history and examination alone? The evidence from studies of children either presenting to headache clinics or who have been diagnosed with brain tumours suggests that tumours are extremely unlikely to present with only headache and no ‘red flag’ symptoms or abnormal signs.1 ,2 ,6 Those who do have headache as the sole initial symptom are likely to develop other features suggestive of a tumour within a few months.1–3 Red flag symptoms include those of raised intracranial pressure, such as nausea, vomiting and diurnal variation (box 1). However, brain tumours can cause headaches and vomiting at any time of day.2 ,3 Red flags, particular to preschool children, include head tilt, new squints, faltering growth, developmental regression, rapid head growth or behaviour change such as irritability or lethargy, disturbed sleep or problems at nursery.3 Lewis also includes headache in any child under 3 years old as a red flag on the basis that primary headache is very uncommon at this stage, and examination can be difficult.7
Worst overnight or early morning
On coughing or straining
In child younger than 3 years
Change in school performance
Nausea or vomiting especially early morning
Seizures, especially focal
Growth and development
Rapid head growth
Where there are no red flag symptoms, abnormalities on examination, or new developments on follow-up, one can be confident that a tumour is extremely unlikely and imaging is not required.
Is it a primary headache?
A primary headache is one which is not associated with another disease process. Tension-type headache and migraine are the predominant primary headache disorders throughout early childhood and into adolescence. Although strict definitions of each are available,8 these are based on adult features and are restrictive when applied to young children, particularly with respect to headache duration.9 Tension-type headache tends to be featureless and mild compared with migraine (table 1). Migraine in preschool children differs from that in older children and adults: the duration is shorter and may be less than an hour, the site is more often bilateral and the pulsating character may not be present or describable. Young children may not describe photophobia or phonophobia, but these can often be inferred from their behaviour.10 ,11
Migraine with aura is relatively rare in preschool children, occurring in only 2% of children with migraine in one study.10 Hemiplegic migraine is rare and should mandate neuroimaging when it occurs.12
Childhood periodic syndromes can be precursors to migraine. They are underdiagnosed, but together have a prevalence of around 5% in the paediatric population.13 They are characterised by paroxysmal symptoms, such as nausea, dizziness, pallor and lethargy, with full recovery and normal neurological examination findings between attacks. They are summarised in table 2.
Other primary headache disorders, such as cluster headache, are extremely rare in this age group, but it is important to recognise these short-duration headache disorders, as treatment is quite different to that of migraine or tension-type headache.
What else could it be?
Other causes of non-acute headache in young children are listed in box 2.
Causes of secondary headaches in children under 515
Vascular lesion (arteriovenous malformation, cavernoma)
Infection (atypical meningitis, abscess)
Venous sinus thrombosis
Epilepsy (peri-ictal headache)
Idiopathic intracranial hypertension (rare in this age group)
Type I Chiari malformation
ENT (otitis media, tonsillitis, sinusitis)
Other infection (eg, pneumonia)
Dental (caries, chronic infection, bruxism)
Ocular (refractive errors)
Cervical spine disorders
Neglect (hunger, dehydration, stress)
Hypercapnoea, hypoxia (sleep apnoea, chronic respiratory disease)
ENT, ear, nose, throat.
Armed with the knowledge about common and serious differential diagnoses, you can now confidently begin the consultation.
A careful history should be sought, particularly looking for red flag symptoms, features of primary headache, and systemic symptoms (boxes 1 and 2, tables 1 and 2). Eliciting a description of the headache from the child can be challenging. Encourage him or her to draw a picture of how the headache feels, or of their visual symptoms. Severity and associated features such as photophobia may be assessed by parental descriptions of behaviour during a headache.11 Home video footage can be useful, especially in childhood periodic syndromes. A positive family history is common but not diagnostically useful in primary headache. Ask about infantile colic and travel sickness, which have often been present in children with migraine.16
Many 4-year-olds can comply with a traditional neurological examination which should include cranial nerves, visual fields, visual acuity, testing for focal motor deficits and signs of ataxia. Younger children require a more opportunistic approach (box 3). At all ages, observation is crucial, and should take place from the very beginning of the consultation. Funduscopy may seem daunting, but it can be achieved by sitting the child on one parent's knee and having them look at the other parent (or nurse, or a video) across the room while you visualise the fundi. If this proves impossible, a referral to ophthalmology should be made. A systemic examination including blood pressure measurement should be performed. If, despite your best efforts, you cannot perform a full examination, then calling the child back for a further appointment is advisable.
Neurological examination in children under 5 (adapted from Edgar A et al17)
Head shape and size (plot the head circumference)
Overall size and proportions (plot the height and weight)
Signs of precocious puberty
Cranial nerves II, III, IV, VI
Eye movements (follow a toy or a light)
Pupil reactions to light
Visual fields (in a very young child a second examiner could bring a toy into the child's temporal vision while first examiner distracts)
Funduscopy (leave until the end)
Other cranial nerves
VII—observe symmetry of smile, facial expressions, try making faces
VIII—second examiner could ring a bell from behind the child
VII, IX, X, XII—ask if they can suck and swallow normally
VII, X, XI—speech, listen for any spontaneous cough, gag
XII—stick out tongue
Upper limb and lower limbs
Observe gait first (include running and tandem walking if developmentally appropriate)
Look for deformity, muscle bulk, posture
Feel for tone
Test power by testing tightness of grasp on toy
Test central tone and balance by pulling to sit from supine
Observe coordination in play
Test reflexes by making it a game
Do not routinely test sensation unless clues to problems in the history or abnormal motor exam
If a space-occupying lesion is suspected on the basis of red flag symptoms or abnormal neurological signs, then neuroimaging should be arranged urgently. Imaging should not be performed just to provide reassurance when the index of suspicion is low, as the risks of radiation, sedation and of incidental findings will generally outweigh the benefits.18 MRI provides a superior level of detail than CT, particularly of posterior fossa structures, avoids radiation exposure, is cost-effective and is the investigation of choice except in emergency situations.19 However, young children may need to be sedated. Other investigations may be indicated depending on the history and examination findings, but are not generally required to diagnose primary headache.
If the patient has neither red flag symptoms nor abnormalities on neurological examination, you can reassure yourself and the family that a sinister cause for the headache is extremely unlikely. Do not be afraid to say the words ‘brain tumour’; explain that you have looked hard for signs of this and that you are happy that there are none. However, if the headache changes in the future, the family should feel empowered to seek a further medical review. One option would be to provide a list of red flag symptoms such as that produced by the HeadSmart Initiative (figure 120).
In children with migraine, acute attacks should be treated early with rest and simple analgesia Addressing lifestyle issues and avoiding known triggers is advisable. Migraine prophylaxis is rarely needed, and there is little evidence for the efficacy of any agent over placebo in this age group.21 Prophylaxis should be considered only in those children with frequent or troublesome episodes after lifestyle issues have been addressed. In children with tension-type headache, attacks often do not need specific treatment. Medication overuse should be avoided by reserving analgesics for severe headaches.15 Again, addressing lifestyle issues may reduce headache frequency. Table 3 summarises the treatment of primary headache. A decision making flowchart, search strategies, and 5 extended matching questions on headache in children under 5 are provided in online appendices 1, 2 and 3 respectively.
Detailed history-taking and examination are crucial when dealing with a child under the age of 5 years with headache. A thorough search for red flag symptoms and abnormal signs will enable the clinician to either swiftly schedule neuroimaging or to reassure the family. Where doubt remains, arranging a formal ophthalmology review and a follow-up appointment are helpful. The majority of young children with primary headache disorders can be treated with reassurance, non-pharmacological methods and simple analgesia.
The authors would like to thank the HeadSmart campaign (http://www.headsmart.org.uk) for granting permission to use the brain tumour symptoms card.
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Contributors NM performed the literature review and wrote the first draft of the manuscript. NM and RH both revised the manuscript and approved the final version.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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