Clinical Pathways
Clinical Pathways
Life Threatening Headaches - Pediatric
Life Threatening Headaches - Pediatric

Life Threatening Headaches - Pediatric

Tags
Ped. Emerg. Med. Practice
Published
May 1, 2023
Author(s)
Sarah Chen, MD Aarti Gaglani, MD Michael J. Stoner, MD

View The Full Pathway

Action

Patient presents with headache. Perform a rapid clinical assessment.

Decision

Unable to protect airway? Not breathing? Hemodynamically unstable?

icon
Yes → Establish advanced airway; Initiate resuscitation

Background

As with all critically ill pediatric patients, initial management prioritizes the airway, breathing, and circulation. If a patient is too altered to protect their airway or is in respiratory failure, consider an advanced airway such as endotracheal intubation. Avoid hypoxia by providing supplemental oxygen. Establish an intravenous (IV) line to provide fluids, analgesics, or other medications as indicated. Close and frequent monitoring of the patient’s vital signs is imperative. It is important to avoid hypotension because any decrease in brain perfusion could worsen neurologic outcomes in the event of certain pathologic headache etiologies. Hypertension could indicate impending brain herniation or PRES. Trauma patients with headache are a special consideration and beyond the scope of this issue.

‣
References
  1. Perry MC, Yaeger SK, Toto RL, et al. A modern epidemic: increasing pediatric emergency department visits and admissions for headache. Pediatr Neurol. 2018;89:19-25. (Database retrospective chart review; 400 patients)
  2. Kabbouche M, Hershey AD. Standardization of pediatric headache evaluation and treatment in the emergency department. J Pediat. 2013;163(6):1545-1546. (Guideline summary)
  3. Conicella E, Raucci U, Vanacore N, et al. The child with headache in a pediatric emergency department. Headache. 2008;48(7):1005-1011. (Retrospective chart review; 432 patients) DOI: 10.1111/j.1526-4610.2007.01052.x
  4. Hsiao HJ, Huang JL, Hsia SH, et al. Headache in the pediatric emergency service: a medical center experience. Pediatr Neonatol. 2014;55(3):208-212. (Retrospective chart review; 409 patients) DOI: 10.1016/j.Pedneo.2013.09.008
  5. Zhou AZ, Marin JR, Hickey RW, et al. Serious diagnoses for headaches after ED discharge. Pediatrics. 2020;146(5):e20201647. (Multicenter retrospective cohort study; 121,621 patients)
  6. Güngör A, Göktuğ A, Bodur İ, et al. Retrospective evaluation of acute headache in pediatric emergency department: etiologies, red flags, and neuroimaging. Neurologist.2022;27(3):95-99. (Retrospective study; 558 patients) DOI: 10.1097/nrl.0000000000000377
  7. Lewis DW, Ashwal, Dahl, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002;59(4):490-498. (Literature review, guideline recommendation)
  8. Raucci U, Della Vecchia N, Ossella C, et al. Management of childhood headache in the emergency department. Review of the literature. Front Neurol. 2019;10:886. (Review)
  9. Khalaf A, Iv M, Fullerton H, et al. Pediatric stroke imaging. Pediatr Neurol. 2018;86:5-18.(Review)
  10. Gerstl L, Badura K, Heinen F, et al. Childhood haemorrhagic stroke: a 7-year single-centre experience. Arch Dis Childh. 2019;104(12):1198-1202. (Retrospective study; 25 patients)
  11. Boulouis G, Blauwblomme T, Hak JF, et al. Nontraumatic pediatric intracerebral hemorrhage. Stroke. 2019;50(12):3654-3661. (Systematic review; 139 articles)
  12. Bigi S, Capone Mori A, Steinlin M, et al. Cavernous malformations of the central nervous system in children: presentation, treatment and outcome of 20 cases. Eur J Paediatr Neurol. 2011;15(2):109-116. (Retrospective multicenter study; 20 patients)
  13. Chen R, Zhang S, You C, et al. Pediatric intracranial aneurysms: changes from previous studies. Childs Nerv Syst. 2018;34(9):1697-1704. (Retrospective observational study; 64 patients)
  14. Dalvi N, Sivaswamy L. Life-threatening headaches in children: clinical approach and therapeutic options. Pediatr Ann. 2018;47(2):e74-e80. (Review)
  15. Chelse AB, Kurz JE, Gorman KM, et al. Remote poststroke headache in children: characteristics and association with stroke recurrence. Neurol Clin Pract. 2019;9(3):194-200. (Single-center retrospective study; 115 patients)
  16. Rollins N, Pride GL, Plumb PA, et al. Brainstem strokes in children: an 11-year series from a tertiary pediatric center. Pediatr Neurol. 2013;49(6):458-464. (Retrospective chart review; 15 patients)
  17. Rafay MF, Shapiro KA, Surmava AM, et al. Spectrum of cerebral arteriopathies in children with arterial ischemic stroke. Neurology. 2020;94(23):e2479-e2490.(Multicenter observational cohort study; 2127 patients)
  18. Goeggel Simonetti B, Ritter B, Gautschi M, et al. Basilar artery stroke in childhood. Dev Med Child Neurol. 2013;55(1):65-70. (Systematic review of the literature, prospective population-based study; 97 patients)
  19. Ferriero DM, Fullerton HJ, Bernard TJ, et al. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019;50(3):E51-E96. (Scientific statement) DOI: 10.1161/STR.0000000000000183
  20. Ichord RN, Benedict SL, Chan AK, et al. Paediatric cerebral sinovenous thrombosis: findings of the International Paediatric Stroke Study. Arch Dis Child. 2015;100(2):174-179.(Multicenter cohort study; 170 patients)
  21. Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke.2011;42(3):613-617. (Multicenter prospective cohort study; 113 patients)
  22. DeLaroche AM, Sivaswamy L, Farooqi A, et al. Pediatric stroke clinical pathway improves the time to diagnosis in an emergency department. Pediatr Neurol.2016;65:39-44. (Prospective cohort review; 36 patients)
  23. Celle ME, Carelli V, Fornarino S. Secondary headache in children. Neurol Sci.2010;31(SUPPL.1):S81-S82. (Review)
  24. Atiq M, Ahmed US, Allana SS, et al. Brain abscess in children. Indian J Pediatr.2006;73(5):401-404. (Retrospective chart review; 30 patients)
  25. Alamarat Z, Hasbun R. Management of acute bacterial meningitis in children. Infect Drug Resist. 2020;13:4077-4089. (Review)
  26. Walter SM, Laderman M, Polk P. Pediatric headache attributed to infection. Semin Pediatr Neurol. 2021;40:100923. (Review)
  27. Herrmann BW, Chung JC, Eisenbeis JF, et al. Intracranial complications of pediatric frontal rhinosinusitis. Am J Rhinol. 2006;20(3):320-324. (Retrospective case series; 16 patients)
  28. Patel NA, Garber D, Hu S, et al. Systematic review and case report: intracranial complications of pediatric sinusitis. IInt J Pediatr Otorhinolaryngol. 2016;86:200-212.(Systematic review and case report; 180 patients)
  29. Lee BE, Chawla R, Langley JM, et al. Paediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study of aseptic meningitis. BMC Infect Dis. 2006;6:68.(Retrospective chart review; 802 patients)
  30. Hicks CW, Weber JG, Reid JR, et al. Identifying and managing intracranial complications of sinusitis in children: a retrospective series. Pediatr Infect Dis J.2011;30(3):222-226. (Retrospective chart review; 13 patients)
  31. Amarilyo G, Alper A, Ben-Tov A, et al. Diagnostic accuracy of clinical symptoms and signs in children with meningitis. Pediatr Emerg Care. 2011;27(3):196-199. (Prospective cohort study; 108 patients)
  32. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics.2013;132(1):e262-e280. (Clinical practice guidelines)
  33. Bambakidis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott’s puffy tumor revisited. Pediatr Neurosurg. 2001;35(2):82-89. (Case series; 7 patients)
  34. Viswanatha B. Lateral sinus thrombosis in children: a review. Ear Nose Throat J.2011;90(6):E28-E33. (Retrospective study; 9 patients)
  35. Sébire G, Tabarki B, Saunders DE, et al. Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome. Brain. 2005;128(3):477-489.(Multicenter prospective study; 32 patients)
  36. Jackson BF, Porcher FK, Zapton DT, et al. Cerebral sinovenous thrombosis in children: diagnosis and treatment. Pediatr Emerg Care. 2011;27(9):874-880. (Review)
  37. Wong SJ, Levi J. Management of pediatric orbital cellulitis: a systematic review. Int J Pediatr Otorhinolaryngol. 2018;110:123-129. (Systematic review; 71 articles)
  38. Goldman RD, Cheng S, Cochrane DD. Improving diagnosis of pediatric central nervous system tumours: aiming for early detection. CMAJ. 2017;189(12):E459-E463. (Review)
  39. Chu TPC, Shah A, Walker D, et al. Pattern of symptoms and signs of primary intracranial tumours in children and young adults: a record linkage study. Arch Disease Child. 2015;100(12):1115-1122. (Retrospective study; 4140 patients) DOI: 10.1136/archdischild-2014-307578
  40. Sheridan DC, Waites B, Lezak B, et al. Clinical factors associated with pediatric brain neoplasms versus primary headache: a case-control analysis. Pediatr Emerg Care.2020;36(10):459-463. (Retrospective case-control study; 334 patients)
  41. Lanphear J, Sarnaik S. Presenting symptoms of pediatric brain tumors diagnosed in the emergency department. Pediatr Emerg Care. 2014;30(2):77-80. (Retrospective chart review; 87 patients)
  42. Wilne S, Collier J, Kennedy C, et al. Presentation of childhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol. 2007;8(8):685-695. (Systematic review, meta-analysis; 74 articles)
  43. Sager G, Kaplan AT, Yalçin S, et al. Evaluation of the signs and symptoms of pseudotumor cerebri syndrome in pediatric population. Childs Nerv Syst. 2021;37(10):3067-3072. (Retrospective study; 94 patients)
  44. Cleves-Bayon C. Idiopathic intracranial hypertension in children and adolescents: an update. Headache. 2018;58(3):485-493. (Review)
  45. Vitaliti G, Pavone P, Matin N, et al. Therapeutic approaches to pediatric pseudotumor cerebri: new insights from literature data. Int J Immunopathol Pharmacol. 2017;30(1):94-97. (Review)
  46. Duarte CM, Vilardouro AS, Rebelo D, et al. Posterior reversible encephalopathy syndrome: characteristics, diagnostic accuracy, prognostic factors and long-term outcome in a paediatric population. Acta neurologica Belgica. 2022;122(2):485-495.(Retrospective descriptive study; 16 patients)
  47. Dao JM, Qubty W. Headache diagnosis in children and adolescents. Curr Pain Headache Rep. 2018;22(3):17. (Review)
  48. Yayıcı Köken Ö, Danış A, Yüksel D, et al. Pediatric headache: are the red flags misleading or prognostic? Brain Dev. 2021;43(3):372-379. (Retrospective chart review; 810 patients)
  49. Yonker M. Secondary headaches in children and adolescents: what not to miss. Curr Neurol Neurosci Rep. 2018;18(9):1-6. (Review)
  50. Lewis DW. Headache in the pediatric emergency department. Sem Pediatr Neurol.2001;8(1):46-51. (Review)
  51. Massano D, Julliand S, Kanagarajah L, et al. Headache with focal neurologic signs in children at the emergency department. J Pediatr. 2014;165(2):376-382. (Prospective cohort study; 101 patients)
  52. Chen TH, Lin WC, Tseng YH, et al. Posterior reversible encephalopathy syndrome in children: case series and systematic review. J Child Neurol. 2013;28(11):1378-1386. (Case series and systematic review; 94 patients)
  53. Tessaro MO, Friedman N, Al-Sani F, et al. Pediatric point-of-care ultrasound of optic disc elevation for increased intracranial pressure: a pilot study. Am J Emerg Med.2021;49:18-23. (Observational study)
  54. Linder SL. Understanding the comprehensive pediatric headache examination. Pediatr Ann. 2005;34(6):442-446. (Review)
  55. Expert Panel on Pediatric Imaging, Hayes LL, Palasis S, et al. ACR Appropriateness Criteria Headache-Child. J Am Coll Radiol. 2018;15(5S):S78-S90. (Evidence-based guideline) DOI: 10.1016/j.jacr.2018.03.017

    56. ®

  56. Luque M, Stambo GW. The use of rapid sequence magnetic resonance imaging of the brain as a screening tool for the detection of gross intracranial pathology in children presenting to the emergency department with a chief complaint of persistent or recurrent headaches. Pediatr Emerg Care. 2021;37(10):e660-e663. (Prospective cohort study; 105 patients) DOI: 10.1097/pec.0000000000002089
  57. Rivkin MJ, deVeber G, Ichord RN, et al. Thrombolysis in pediatric stroke study. Stroke.2015;46(3):880-885. (Cohort study)
  58. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284. (Practice guidelines) DOI: 10.1086/425368
  59. Michos AG, Syriopoulou VP, Hadjichristodoulou C, et al. Aseptic meningitis in children: analysis of 506 cases. PLoS One. 2007;2(7):e674. (Retrospective study; 506 patients)
  60. Türay S, Kabakuş N, Hanci F, et al. Cause or consequence: the relationship between cerebral venous thrombosis and idiopathic intracranial hypertension. Neurologist.2019;24(5):155-160. (Retrospective study; 26 patients)
  61. Frühwald MC, Rutkowski S. Tumors of the central nervous system in children and adolescents. Dtsch Arztebl Int. 2011;108(22):390-397. (Review)
  62. Kochanek PM, Adelson PD, Rosario BL, et al. Comparison of intracranial pressure measurements before and after hypertonic saline or mannitol treatment in children with severe traumatic brain injury. JAMA Netw Open. 2022;5(3):e220891. (Comparative effectiveness study; 1000 patients) DOI: 10.1001/jamanetworkopen.2022.0891
  63. Chern JJ, Macias CG, Jea A, et al. Effectiveness of a clinical pathway for patients with cerebrospinal fluid shunt malfunction. J Neurosurg Pediatr. 2010;6(4):318-324.(Prospective study; 245 patients)
  64. Mollan SP, Davies B, Silver NC, et al. Idiopathic intracranial hypertension: consensus guidelines on management. J Neurol Neurosurg Psychiatry. 2018;89(10):1088-1100.(Consensus guideline statement, comprehensive systematic literature review)
  65. Grech C. Ventricular-peritoneal (VP) shunt malfunction in children: the need for a high index of suspicion. Aust Crit Care. 2015;28(1):52-52. (Retrospective review; 11 patients)
  66. Razmara A, Jackson EM. Clinical indicators of pediatric shunt malfunction: a population-based study from the nationwide emergency department sample. Pediatr Emerg Care. 2021;37(11):e764-e766. (Retrospective study; 74,551 observations)
  67. Li K, Yang Y, Guo D, et al. Clinical and MRI features of posterior reversible encephalopathy syndrome with atypical regions: a descriptive study with a large sample size. Front Neurol. 2020;11:194. (Retrospective study; 556 patients)
  68. Gozubuyuk AA, Dag H, Kacar A, et al. Epidemiology, pathophysiology, clinical evaluation, and treatment of carbon monoxide poisoning in child, infant, and fetus.North Clin Istanb. 2017;4(1):100-107. (Review)
  69. Tsze DS, Ochs JB, Gonzalez AE, et al. Red flag findings in children with headaches: prevalence and association with emergency department neuroimaging. Cephalalgia.2019;39(2):185-196. (Prospective cohort study; 224 patients) DOI: 10.1177/0333102418781814
  70. Nigrovic LE, Malley R, Macias CG, et al. Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis. Pediatrics.2008;122(4):726-730. (Retrospective comparative study; 231 patients)

Want more?

Get the full article 👇

Full Pediatric Secondary Headaches Pathway
Full Pediatric Secondary Headaches Pathway
Evaluation
Evaluation

FacebookTwitterLinkedInInstagramYouTube

EB Medicine

FOAMed

Podcast

© EB Medicine. All rights reserved