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Referral Guidelines

Headache Program


Provider’s initial evaluation may include:

  • Asking 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 sounds sensitivity, or nausea
    • Migraine headaches are bifrontal or unilateral moderate to severe intensity headaches associated with a throbbing quality, worsening with activity, and light or sound sensitivity, nausea and/or vomiting
    • Migraine aura may occur before or during headaches lasting 5-60minutes and include sensations of visual changes (dark or bright spots or lines), sensory changes (tingling, numbness), or speech changes
  • Considering other common causes of headache:
    • Sinus headache
    • Post traumatic/concussive headache
    • Allergic rhinitis
    • Ophthalmologic problems
    • Depression

Provider should instruct family on basic first line treatment for headaches including:

  • Lifestyle modification for prevention of headaches including:
    • 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 3 days per week for 30 minutes
    • Sleep per AAP guidelines with no more than two hours of variability in sleep or wake timing
    • Eat 3 healthy well balanced meals per day
  • Abortive therapy when child gets a headache includes:
    • Ibuprofen 10mg/kg per dose up to three days per week
    • 8-12oz 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 and include cyproheptadine (max 0.25mg/kg/day) and amitriptyline (max 1mg/kg QHS)

Provider may consider testing in patients who:

  • Patients with recurrent headache and a normal neurologic exam generally do not require additional testing.
  • 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 systemic complaints including arthralgias, rash, sleep complaints

Providers may consider initiating referral to child neurology when:

  • Patients with a new severe headache of acute onset, headache with focal neurologic deficit or papilledema should be referred to the Emergency Department for neuroimaging
  • Recurrent headache that has been present for at least six months and is not responding to standard medical treatment including lifestyle modification and acute abortive treatment
  • Headache that is resulting in missed school days, worsening of school participation (declining grades, extracurricular activity limitation)

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 that may be helpful.

Headache Program - Departments & Programs - Children's National Medical Center