At Children’s National, we value the importance of well-informed and well-equipped health providers. Here are some referral guidelines suggested for healthcare providers for referring patients to the Headache Program:
Provider’sinitial evaluation mayinclude:
- 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 5-60 minutes 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
Provider should instruct family on basic first line treatment for headaches including:
Provider may consider testing in patients who:
- 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 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 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)
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 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 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.
Download a pdf of these guidelines.
We currently have 3 major types of appointments for headache patients: urgent headache access, chronic multidisciplinary clinic, and behavioral pain medicine appointments.
- Urgent headache appointments – patients should call 202-476-HEAD from 8:30am-4pm M-F or email firstname.lastname@example.org and ask for an “urgent headache appointment” to be scheduled within 5 days of the call with one of our headache providers in the Fairfax PSV, Annapolis, Laurel, Rockville, or DC locations. They will be seen for a 30-60 min appointment with one of our headache specialists and be provided with a comprehensive assessment and management plan.
- Chronic multidisciplinary clinic appointments - patients should call 202-476-HEAD from 8:30am-4pm M-F or email email@example.com and ask for an “chronic multidisciplinary headache appointment”. Patients will be scheduled in the next available appointment (currently booking 3 months in advance) to have a multidisciplinary appointment with both neurology and behavioral pain medicine. A comprehensive evaluation and management plan will be provided. The team will determine if additional management is appropriate including pain focused cognitive behavioral therapy, relaxation therapy, biofeedback, nerve blocks, acupuncture, or infusion treatment.
- Behavioral pain medicine appointments - You must place the order from the outpatient encounter you last saw them. Under orders you type “Refer Pain Clinic” and then select the option for “Pain Med Psy” as shown below. This is if they have already seen a neurologist and need to be seen by behavioral pain medicine only. Families will be called once the order is placed and they are next on the queue.