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.

Initial Evaluation and Management

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 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 5-60 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

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

Lifestyle modification

• 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 three 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

• 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 brain imaging studies in patients who have: 

• Headaches for less than six 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 may be done for children with other systemic complaints including arthralgias, rash, sleep complaints.

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

When to Refer

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)

How to Refer

• Appointment line: 202-476-HEAD (4323)
• After hours: 202-476-3611

If you have a question about referral criteria please email Jessica Keats-Chester, headache coordinator, at headache@childrensnational.org.

What to Expect from a Visit to Children's National

• Detailed history headaches, past medical history and family history
• Focused physical 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.