Pediatric headaches are a common issue in emergency departments (EDs), presenting unique challenges in diagnosis and management.
Objectives
This review aims to explore the current landscape of pediatric headache management in EDs, identify challenges, and suggest solutions.
Methods
A narrative review was conducted using PubMed, Scopus, and Google Scholar to gather literature on pediatric headache management in EDs. Articles published in English within the last 10 years were prioritized, with key older studies considered. Inclusion criteria focused on studies addressing pediatric headache management in ED settings, while exclusion criteria removed studies on adult populations, non-ED settings, and non-peer-reviewed articles.
Results
The review highlights the complex nature of pediatric headaches, encompassing diverse presentations and underlying causes. Challenges include difficulties in accurate diagnosis, variations in treatment approaches, and the need for interdisciplinary care. Recent advancements in technology and non-pharmacologic treatments have shown promise.
Conclusion
Effective pediatric headache management in EDs requires improved diagnostic strategies, a multidisciplinary approach, and ongoing research to enhance patient treatment options and outcomes.
Hinweise
Publisher's Note
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Introduction
Headache is a prevalent issue among children, with a notable rise in childhood migraines over the past 30 years. This surge may be linked to changes in children's lifestyles [1]. The diagnosis and management of headaches in pediatric patients are complicated due to their diverse presentations, underlying causes, and triggers [2].
Secondary headaches in children can present differently compared to adults, possibly due to varying levels of brain maturation. Headache disorders are a significant cause of school absences, negatively impacting academic performance and daily activities. They are also a frequent source of stress for both children and their parents [3]. Headaches are the most common neurological symptom in children, with a prevalence estimated at around 58.4%. Tension headaches are the most common type, lasting from 30 min to 7 days and characterized by pressing or tightening pain [4].
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They are often triggered by factors such as stress, depression, anxiety, or poor sleep quality and occur during weekdays, aligning with school hours. Understanding and effectively addressing these challenges in the emergency department setting is crucial for improving outcomes for pediatric patients [5].
Headache in children is a significant concern due to its high prevalence and impact on their health and daily functioning. Children with headaches experience higher hospitalization rates compared to those without, with annual hospitalization rates of 5.1% and 1.7%, respectively [6]. Non-traumatic headaches account for 0.7% to 2.6% of visits in pediatric emergency departments, with hospital admission rates ranging from 8 to 29%. Headache presentations are rarely isolated and are often accompanied by additional symptoms such as fever, sore throat, neck pain, and vomiting [7, 8]. The predominant types of headaches in this age group include migraines and tension headaches, with migraines being more common in younger children and tension headaches becoming more prevalent in adolescence. The differential diagnosis for pediatric headaches is broad, encompassing benign conditions like viral infections, sinusitis, and pharyngitis, as well as more serious secondary causes such as brain tumors, central nervous system infections, and intracranial hemorrhage. Secondary life-threatening causes, although less common, necessitate urgent attention due to their potential for high mortality and morbidity [1].
Managing pediatric headaches in the ED is challenging due to their diverse presentations and overlap with other symptoms, complicating accurate diagnosis. Primary headaches are often underdiagnosed in children due to differences in clinical characteristics compared to adults. There is a pressing need for improved management strategies in the pediatric ED [9, 10].
Thus, this study aims to review the challenges and comprehensive solutions to the management of pediatric headaches in the emergency department.
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Methodology
This narrative review utilized PubMed, Scopus, and Google Scholar to explore recent literature on pediatric headache management in emergency departments (EDs). Keywords included “pediatric headache,” “emergency department,” “acute headache management,” and “non-pharmacologic interventions.” Studies published in English over the past 10 years were prioritized, with key older studies considered as needed. Inclusion criteria included articles focused on pediatric headache management in ED settings, addressing diagnosis, treatment, and recent innovations. Excluded were studies on adult populations, non-ED settings, and non-peer-reviewed articles. Only full-text studies meeting relevance and quality standards were selected to provide an overview of current challenges, practices, and future directions in pediatric headache care within EDs.
Epidemiology of pediatric headaches in the emergency department
Headaches in children can be concerning and might be caused by a range of issues, from benign to more serious conditions. It is a common neurological symptom affecting up to 58.4% of the pediatric population. Headache accounts for 0.6 to 1.3% of all pediatric emergency department admissions, making it the primary cause of these instances [5]. A study conducted by Perry et al. showed that the prevalence of pediatric emergency department visits for headaches grew by 166% (18,041 in 2003 and 48,020 in 2013) in the United States [11].
A systematic review found that benign secondary headaches (35.4–63.2%) and primary headaches (21.8–66.3%) are the most frequent causes of non-traumatic headaches in the ED. There is a lower incidence of life-threatening (LT) secondary headaches (2–15.3%). [12] The most common reason for benign secondary is related to URTI. Typically, headaches are not a standalone complaint; instead, they are frequently accompanied by additional symptoms like fever, sore throats, neck pain, and vomiting. Migraine headaches are the most prevalent type of recurring headache in children, whereas tension headaches are more common in teenagers.
Socioeconomic status can impact headache prevalence. Children from lower socioeconomic backgrounds may get headaches more frequently, potentially as a result of stress, poor diet, and limited access to medical care.
The prevalence of headaches is also influenced by age, race, and sex. Compared to men, women have headaches more frequently. In early childhood (< 14 years old), migraine affects both sexes equally; however, in adolescence and early adulthood, migraine affects more women than men. The results of this investigation support the commonly stated finding that children under the age of 14 had a much lower prevalence of migraines than children in general [12].
Compared to Blacks and Hispanics, Caucasians are also more likely to experience migraine headaches. Patients were split 70.9% Caucasian, 29.1% Black, and 0.9% Hispanic [11]. In the pediatric population, headaches are a prevalent problem that varies in frequency according to age, gender, and race. The most common type of headache is tension-type headache, while migraines are more common in adolescence, especially in females. Ultimately, even though headaches are a common presentation in emergency rooms for children, distinguishing between primary and secondary headache problems and providing the right care requires a thorough evaluation. (Table 1).
Table 1
Pediatric headache classification: types, triggers, and management
Headache Type
Characteristics
Common Triggers
Management
Primary headaches
Migraine (with/without aura)
Unilateral, pulsating, moderate to severe intensity, duration 2–72 h
Stress, certain foods, hormonal changes
NSAIDs, triptans for acute attacks; preventive medications (e.g., amitriptyline) for chronic cases
Tension-Type Headache (TTH)
Bilateral, non-pulsating, mild to moderate intensity, duration 30 min to 7 days
Stress, poor posture, fatigue
NSAIDs, acetaminophen; relaxation techniques
Cluster Headache
Severe unilateral pain around the eye lasts 15–180 min and occurs in clusters
Alcohol, smoking, strong odours
Oxygen therapy; triptans for acute management; preventive treatments (e.g., verapamil)
Secondary headaches
Headaches due to Trauma
Sudden onset after head injury
Head trauma
Imaging studies (CT/MRI) if indicated; symptomatic treatment
Vascular Disorders
Sudden severe headache (e.g., subarachnoid hemorrhage)
Hypertension, vascular malformations
Emergency evaluation; possible surgical intervention
Infection
Associated with fever and other systemic symptoms
Viral/bacterial infections
Treat underlying infection; symptomatic relief with analgesics
Increased Intracranial Pressure
Gradual worsening headache, often worse in the morning
Tumors, hydrocephalus
Imaging studies; treat underlying cause
Diagnostic challenges
Pediatric headaches are a complex and diverse condition, with a standardized classification scheme by the International Headache Society (IHS) called the ICHD-3. However, the practical application in an emergency department setting can be challenging. One significant challenge is differentiating between primary and secondary headaches [13].
Primary headaches, such as migraines and tension-type headaches, account for a large proportion of pediatric cases. Migraines, which can account for 21.8% to 66.3% of primary headaches, are characterized by unilateral, pulsating pain of moderate to severe intensity, often accompanied by nausea, photophobia, and phonophobia [4]. However, the ICHD-3 requires a minimum of five headache episodes for a migraine diagnosis, which can be limiting in an ED setting where time constraints and immediate symptom relief are priorities [3, 14].
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Secondary headaches due to more serious underlying conditions must also be considered, which can arise from brain tumours, central nervous system infections, or intracranial hemorrhages and may present with symptoms that overlap with primary headaches but may also include red flags like sudden onset, focal neurological deficits, or altered consciousness, requiring neuroimaging and other diagnostic tests to exclude life-threatening causes [15].
The variability in how headaches present in children versus adults adds another layer of complexity. Migraines with aura are less common in younger children and more prevalent in adolescents, requiring specialized knowledge to differentiate between these conditions. Episodic syndromes associated with migraines, such as cyclic vomiting syndrome (CVS) and abdominal migraine, also present with symptoms overlapping with other conditions. Differentiating these conditions from more serious vestibular or neurological disorders requires a thorough assessment and sometimes neuroimaging [16, 17].
Tension-type headaches (TTH) are prevalent among children, affecting 5–25% of the pediatric population. TTH is characterized by consistent, mild to moderate pain that is usually bilateral and not associated with additional symptoms. The pain typically intensifies during the afternoon, coinciding with the school day, and may persist for about 2 h per episode, occurring roughly twice a month. Children with TTH often continue their usual activities despite the headache, making the condition less disruptive compared to migraines [4].
Diagnosing TTH is critical due to its lack of migraine-associated features and the pain of TTH being described as a pressing or tightening sensation rather than the pulsating pain typical of migraines. Changes in headache characteristics from preschool age to adolescence also complicate diagnosis, making it necessary for clinicians to be vigilant for red flags. These red flags, such as significant changes in headache pattern or intensity, warrant further investigation, including neuroimaging, to rule out secondary causes that may present similarly to TTH but are potentially more serious [1, 4].
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Trigeminal autonomic cephalalgias (TACs) encompass several rare but severe headache syndromes, including cluster headaches (CH), paroxysmal hemicranias (PH), and short-lasting unilateral neuralgiform headache attacks with conjunctival tearing and injection (SUNCT). These headaches are marked by unilateral pain accompanied by significant autonomic features such as conjunctival injection, lacrimation, nasal congestion, and ptosis. In children, CH is particularly rare, with an incidence ranging from 0.03% to 0.1% of pediatric headaches and a male predominance. The onset typically occurs during adolescence [18, 19].
Pediatric patients, particularly younger children, often struggle with accurately describing their headache symptoms, which can complicate the diagnostic process [20‐22]. They may describe headaches in non-specific terms or through behavioral changes, requiring careful interpretation and a thorough clinical history [23, 24]. A detailed clinical history and physical examination are crucial for accurate diagnosis, considering factors like onset, duration, frequency, associated symptoms, and recent trauma or infections [21, 25].
A neurological assessment is also essential. However, the subtlety of signs in younger children can make this challenging. Psychological factors like stress or anxiety can also influence headaches, which can be exacerbated by the acute setting of the emergency department [26, 27]. Socio-economic factors and family history also impact the presentation and management of headaches, necessitating a holistic approach. [28] (Table 2).
Table 2
Diagnostic methods and challenges in pediatric headache evaluation
Diagnostic Method
Description
Challenges
Clinical History
Comprehensive assessment of headache characteristics, triggers, and frequency
Reliance on subjective reports; difficulty in young children
Neurological Examination
Assessment for focal neurological signs or abnormalities
Variability in examination findings; may miss subtle signs
Neuroimaging (CT/MRI)
Used to rule out secondary causes in atypical presentations or red flags
High rates of incidental findings; concerns over radiation exposure
Laboratory Tests
Blood tests or CSF analysis if secondary causes are suspected
Limited utility in primary headaches; may lead to unnecessary procedures
Electroencephalography (EEG)
Evaluates for seizure disorders in atypical cases
Not routinely recommended; low yield for primary headache disorders
Headache Disability Assessment
Tools like PedMIDAS to evaluate the impact on quality of life
May not capture all dimensions of disability; requires validation in diverse populations
Management strategies in the PED
Management of acute pediatric headaches in the emergency department (ED) focuses on symptom relief, early diagnosis, and recognizing life-threatening causes through detailed history-taking and physical examination. Guidelines from the American Academy of Neurology (AAN) and the American Headache Society (AHS), endorsed by the American Academy of Pediatrics recommends acetaminophen, NSAIDs (e.g., ibuprofen), and triptans for managing acute migraines in children, tailored by age, weight, and route of administration [29]. Non-pharmacologic measures, such as a dark room and cool compress, are also recommended by the International Headache Society (IHS), often prioritizing these methods over medication [30].
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For first-line pharmacologic treatment, oral acetaminophen (15 mg/kg, max 1 g) or ibuprofen (10 mg/kg) is often effective, with acetaminophen showing minimal side effects and ibuprofen leading to quicker migraine resolution [29, 31, 32]. If these fail, triptans may be used; FDA-approved options include almotriptan, sumatriptan with naproxen, zolmitriptan nasal spray (for ages 12 +), and rizatriptan (for ages 6–17). These treatments, particularly nasal sprays, are effective but should be used cautiously, noting contraindications [29, 31]. Naproxen and ergot derivatives, though present in adult guidelines, lack pediatric studies and are less frequently recommended [29].
In cases of refractory headaches or severe attacks, combining NSAIDs with triptans, such as sumatriptan/naproxen, can be effective. For prolonged migraines (status migrainosus), intravenous hydration and antiemetics may be needed. Promethazine (0.25–0.5 mg/kg) is a preferred antiemetic for children over two years due to a lower risk of extrapyramidal side effects, while prochlorperazine (0.15 mg/kg) remains a secondary choice due to its side-effect profile [30, 33]. Metoclopramide, ketorolac, and ondansetron have also demonstrated efficacy and safety in treating pediatric migraines [30, 34].
For managing tension-type headaches, acetaminophen and NSAIDs are typical choices, complemented by non-pharmacologic methods such as relaxation, strength exercises, biofeedback, and mindfulness therapy. While no single non-pharmacologic method has proven superior, lifestyle changes, such as stress reduction and regular sleep, are beneficial [35, 36].
Cluster headache treatments in pediatric patients include 100% oxygen therapy and triptans. Although sumatriptan is effective in adults, its pediatric use is less clear, requiring further study to confirm efficacy and safety [37, 38]. Pediatric headache management in the ED could benefit from more robust research and validated clinical trials to support these therapies.
Empowering patients and families to recognize triggers, adopt preventive lifestyle changes, and maintain a headache diary for follow-up care can enhance long-term control and quality of life. Follow-up after ED discharge is crucial for evaluating preventive treatments and improving symptom management [39, 40].
Pitfalls in management
Misdiagnosis is a significant challenge in pediatric headache management, particularly in distinguishing primary headaches, such as migraines, from secondary, potentially life-threatening causes. Cases like a child misdiagnosed with constipation for a post-lumbar puncture headache or a delayed diagnosis of infratentorial empyema after initial treatment for sinusitis underscore the complexity of accurate diagnosis. In another instance, a boy presenting with persistent headaches and fever was repeatedly diagnosed with migraines until a fatal brain abscess was discovered, stressing the importance of thorough investigation when standard treatments fail [41‐43].
Emergency physicians play a crucial role in quickly identifying serious causes of pediatric headaches to minimize unnecessary admissions [44]. Conditions like brain tumors, meningitis, and idiopathic intracranial hypertension must be distinguished from benign conditions [45‐47]. Guidelines recommend considering specific symptoms, such as rapid progression, occipital pain, extreme intensity, and abnormal neurologic signs, as potential indicators of serious underlying conditions [48, 49]. Imaging and clinical algorithms are helpful, though benign secondary headaches are far more common than life-threatening causes [45, 50, 51].
Distinguishing between preseptal and orbital cellulitis poses another diagnostic challenge; failure to identify the latter could lead to under- or overtreatment [52, 53]. Lyme neuroborreliosis and Posterior Reversible Encephalopathy Syndrome (PRES) also often present with nonspecific symptoms, complicating the differentiation between primary and secondary headaches [54‐56]. Similarly, chronic carbon monoxide (CO) poisoning, which can cause persistent headaches, may be mistaken for migraines, particularly during colder months [57, 58].
Overuse of imaging in pediatric headache management can lead to unnecessary radiation exposure and delays in appropriate treatment [59]. Despite recommendations against routine imaging for uncomplicated headaches, many patients still undergo scans due to a low diagnostic threshold and fear of missing serious conditions. This overreliance on imaging highlights the need for a more judicious approach, emphasizing red-flag symptoms to guide decision-making [60‐62]. The mnemonic SNOOP4Y (systemic symptoms, neurologic signs, sudden onset, early morning onset, positional worsening, and Valsalva-induced symptoms) helps clinicians recognize warning signs requiring imaging, limiting unnecessary interventions [63]. Fig. 1.
Fig. 1
Clinical decision-making for pediatric headache management
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Medication-overuse headache (MOH) is a growing issue resulting from chronic headache medication overuse, affecting around 1–2% globally [64]. Effective management involves medication withdrawal, though evidence-based strategies are limited. Studies suggest that about half of patients with headaches more than 15 days a month may develop MOH, with symptom improvement often seen following withdrawal (Fig. 2) [65‐70]. The mechanisms vary, as opioids and triptans, for instance, elevate calcitonin gene-related peptide (CGRP) levels, which contribute to neurogenic inflammation and headache pain. Chronic use of analgesics like paracetamol may increase cortical spreading depression (CSD) frequency, suggesting another pathway for MOH [68, 69].
Fig. 2
Timeline of pediatric headache management trends
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Efficient MOH management emphasizes starting detoxification in primary care and handling less complex cases at this level to streamline specialist resources [71‐76]. Complex cases requiring intensive treatment can then be referred to headache clinics or neurologists, creating an organized pathway for MOH management [77, 78].
Continuity of care and effective communication are essential in pediatric headache management. Communication barriers, such as inconsistent team interactions and insufficient training, impede effective care delivery, emphasizing the need for consistent follow-up. Studies highlight the importance of validated clinical tools to guide decision-making in the emergency department, reducing unnecessary imaging and ensuring prompt management of cases needing immediate intervention (Table 3) [77].
Table 3
Pitfalls in pediatric headache management
Pitfall
Description
Consequences
Medication Overuse
Frequent use of acute headache medications can lead to medication-overuse headache (MOH)
Increased headache frequency and severity; chronicity of headaches
Inadequate Assessment
Failing to conduct a thorough clinical history and neurological exam may overlook serious conditions
Misdiagnosis or delayed treatment of secondary headaches
Relying Solely on Pharmacotherapy
Overemphasis on medications without integrating non-pharmacological approaches (e.g., lifestyle changes)
Reduced effectiveness of treatment; poor long-term outcomes
Inconsistent Follow-Up
Lack of regular follow-up can hinder monitoring of treatment efficacy and adjustments needed
Persistent symptoms; missed opportunities for intervention
Ignoring Psychological Factors
Neglecting the role of stress, anxiety, and behavioral issues in headache management
Failing to provide clear instructions regarding medication use and lifestyle modifications
Confusion, non-compliance, and ineffective management strategies
Special considerations
Children with unique needs or co-occurring illnesses present special challenges in pediatric headache management, requiring emergency department (ED) practitioners to consider biological, cultural, and socioeconomic factors that influence headache presentation and treatment [11]. Diagnosing headaches in children with neurological conditions, developmental delays, or disorders such as cerebral palsy and autism spectrum disorder (ASD) can be complex. These children may have difficulty describing their pain, which complicates assessments of headache type, frequency, or intensity [78].
In addition, children with genetic disorders or epilepsy may already be on long-term medications that interact with headache treatments. For instance, some anticonvulsants used to treat epilepsy also prevent migraines, but medication side effects and interactions must be carefully managed. Physicians must balance treating both the headache and the child’s underlying condition without worsening overall health [76]. A multidisciplinary approach, including pediatricians, neurologists, and pain specialists, is often recommended to create a tailored treatment plan for these patients, combining medication adjustments with non-pharmacological methods like cognitive-behavioral therapy [75, 76].
Cultural and socioeconomic factors significantly impact pediatric headache treatment. Cultural views on pain and health can influence when families seek medical care. Some parents may consider headaches a routine issue and delay medical intervention until the pain becomes severe, while others might prioritize traditional treatments over evidence-based approaches [64, 65]. Socioeconomic status (SES) also plays a critical role. Low SES often limits healthcare access due to issues like lack of insurance, transportation, or ability to afford prescriptions. Consequently, children from low-income backgrounds with recurrent headaches may rely more on ED visits than regular primary care [77, 78].
Children from low SES backgrounds are also exposed to factors that may worsen headache symptoms, such as chronic stress related to financial instability or food insecurity. ED practitioners need to recognize these external influences and, where possible, coordinate with social workers or local support services for additional family assistance [71].
Another prevalent issue in ED headache management is over-reliance on acute treatments like triptans or NSAIDs, which offer temporary relief but do not address the root causes of recurrent headaches. Excessive use of these medications can lead to medication-overuse headaches, compounding the patient's headache burden [61]. Non-pharmacological strategies, including lifestyle modifications, are equally important. Practicing good sleep hygiene, regular physical activity, and stress management can help reduce headache frequency. Patient education should emphasize nutrition, hydration, and avoiding common headache triggers such as caffeine or specific foods. Addressing psychosocial triggers, such as school-related stress or excessive screen time, is also essential for teens [62].
For effective long-term management, continuous monitoring and a structured care plan are necessary, ideally involving a pediatric neurologist or headache specialist. Education for both the child and family on the proper use of preventive measures and acute therapies fosters adherence to long-term care goals [61, 63].
Legal and ethical considerations in pediatric headache management
In the emergency department (ED), legal and ethical considerations must be carefully considered while managing headaches in children [13]. These factors are essential to guaranteeing the child's safety as well as the provider's adherence to medical laws. Three main topics will be covered in this section: the ethical difficulties in striking a balance between acute and long-term treatment, the legal ramifications of misdiagnosis or delayed diagnosis, and informed permission and assent [14].
A fundamental component of medical practice, informed consent is necessary for making moral decisions. Obtaining permission in pediatric treatment poses distinct issues due to kids' legal incapacity to offer full consent on their own [65]. Usually, parents or legal guardians are in charge of making healthcare decisions. To the extent of their developmental capacity, young patients should still be included in the decision-making process; this is known as "assent" [66].
To obtain assent, the condition and available treatments must be explained in a way that is suitable for the child's age and comprehension. Youngsters are given the chance to voice any preferences, worries, or objections [67]. Their participation guarantees that people are regarded as individuals and helps to build trust, even though their consent is not legally enforceable. For example, when it comes to headache therapy, a kid who gets headaches regularly may be asked for their opinion on pain management techniques. This would include them more and help them feel less anxious about receiving treatment [56, 58].
In this situation, caregivers have an ethical duty to strike a balance between the child's autonomy and parental authority. It's crucial to have open lines of communication with the child's parents as well, particularly when talking about intricate treatment regimens or prescription drugs that could have long-term effects [77, 78].
Pediatric patients' headaches can indicate a variety of illnesses, from benign tension headaches to potentially fatal disorders like meningitis or brain tumors. It can be challenging to determine the exact reason for a headache, particularly in younger children whose symptoms may not be well communicated. When it comes to treating kid headaches, a delayed or incorrect diagnosis might have major legal ramifications for medical professionals [77].
If a benign tension-type headache or migraine is mistakenly classified as a brain tumor, which is a dangerous condition, the delay in starting treatment might cause permanent damage. Legal claims for medical malpractice may occur in such circumstances [69]. The main focus of medical malpractice lawsuits is usually on whether the doctor adhered to the standard of care, which is determined by what a qualified practitioner would do in a comparable situation. The supplier could be held accountable for damages if it turns out that they did not live up to this requirement [69].
Although emergency rooms are meant to treat acute conditions, many children's headache cases—especially those with migraines or persistent tension headaches—need long-term treatment plans. The moral conundrum is how to cure a headache while taking into account its longer-term, wider effects while yet offering prompt relief [70].
Healthcare professionals have an ethical obligation to incorporate both acute and long-term care into their treatment regimens. To maintain continuity of treatment after the emergency room, collaboration with the child's primary care physician or a specialist is necessary [103]. Maintaining patient-centered care requires open discussion regarding the possible advantages and disadvantages of acute therapies as well as long-term headache preventive techniques [74].
Emerging trends and innovations in pediatric headache management
Emerging trends in pediatric headache management emphasize improved diagnostics and innovative treatments, such as functional MRI (fMRI), mobile health tools, CGRP inhibitors, and cognitive behavioral therapy (CBT). Functional MRI and other neuroimaging methods like MRS enhance understanding of headache mechanisms by depicting brain function and biochemical changes during headache episodes. These tools aid clinicians in differentiating between primary and secondary headaches, boosting diagnostic accuracy [75]. Digital headache diaries, often linked to mobile apps, provide real-time data on headache frequency and triggers, enabling personalized treatment adjustments [71, 72].
Pharmacologically, new trials on monoclonal antibodies targeting CGRP have shown promise in reducing migraine frequency in adolescents, while updated formulations of triptans may offer better tolerability for pediatric patients [72, 73]. Non-drug therapies, including CBT and biofeedback, address the psychological aspects of headaches, helping children develop effective coping strategies without medication side effects [61]. Emerging non-invasive brain stimulation methods like TMS and VNS also show potential in treating resistant pediatric headaches.
Telemedicine has transformed pediatric headache care, especially since COVID-19, by connecting families with headache specialists regardless of location. It incorporates virtual headache diaries and remote monitoring, allowing for timely management adjustments based on electronically shared information [74]. This model facilitates comprehensive care with input from multiple specialists, ideal for complex headache cases [75]. These innovations in pediatric headache management—spanning diagnostics, pharmacology, and telemedicine—signal a future where treatments are more precise, accessible, and patient-centered, significantly enhancing outcomes for children with headache disorders (Table 4).
Table 4
Emerging trends in pediatric headache management
Trend/Direction
Description
Implications for Practice
Increased Focus on Psychological Interventions
Growing evidence supports Cognitive Behavioral Therapy (CBT) and mindfulness as effective treatments for chronic migraines
Integrating psychological therapies as first-line treatments can reduce reliance on medications and their side effects
Biopsychosocial Approach
Emphasis on a holistic treatment model that combines medical, psychological, and lifestyle interventions
Enhances overall patient outcomes by addressing multiple facets of headache disorders
Telehealth and eHealth Solutions
Expansion of remote psychological therapies and telemedicine for headache management, increasing access to care
Facilitates timely interventions, especially for patients in remote areas
Personalized Treatment Plans
Tailoring interventions based on individual patient profiles, including headache type, severity, and comorbidities (Fig. 3)
Improves treatment efficacy and patient compliance through customized care
Integration of Complementary Therapies
Incorporation of acupuncture, biofeedback, and relaxation techniques alongside conventional treatments
Offers additional options for patients who may not respond well to pharmacotherapy
Research on Medication Overuse
Ongoing studies to better understand the impact of medication overuse headaches (MOH) in pediatric populations
Informs guidelines for safe medication use and prevention strategies
Fig. 3
Overview of comorbidities associated with pediatric headaches
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Future directions and recommendations
An important area for more research is finding good treatments made just for children. The CHAMP study showed that there wasn’t much difference between amitriptyline & topiramate when compared to a placebo in children, and this shows how tricky it is to treat migraines in children, especially because they often respond strongly to placebos in trials [62]. To tackle these issues, future studies need to follow International Headache Society (IHS) guidelines [64]. It’s important to think about how children experience migraines differently and how placebos affect them.
Plus, there’s a lot of interest in trying out non-drug treatments like cognitive behavioral therapy (CBT) and non-invasive neuromodulation devices that could give us more options [63, 65]. Still, we need medicines made just for children with migraines because, right now, there aren't any. We’re all looking forward to the results from ongoing studies on both prevention and treatment since they might help improve how we diagnose and manage migraines in pediatric emergency departments.
Additionally, future research needs to focus on finding better treatments for Ewing sarcoma (EwS) since the current methods aren't very specific, and there is a lot of promise in the CALCB/RAMP1 axis as a new target for therapy [64]. Some studies show that blocking pathways can slow down EwS cell growth, and using CGRP receptor inhibitors—those are already helping with migraines—might also work for EwS [65]. It’s worth checking out!
There’s a real need to improve ways to diagnose children at the pediatric emergency departments (PEDs). Signs like nocturnal awakenings and occipital pain happen a lot, but they don't mean there's a life-threatening problem, and it’s super important to make clinical decision tools clearer & to use brain scans more wisely so patients don’t have to go through extra tests that aren't needed, and training for doctors at the PED should get better (Fig. 1) [66], so they need to tell the difference between serious & benign headaches. Plus, getting neurologists involved could help a lot. This way, we can avoid wrong calls on diagnoses.
There’s a limit to the International Classification of Headache Disorders-II (ICHD-II) for diagnosing tension-type headaches (TTH) and migraines in children, and it says we need new ways to define cases that look at behaviors & features that aren’t covered right now [76, 77]. Family history matters a lot in these diagnoses, too. We need to do more research on children who come into PED to make sure we can diagnose them better and treat them effectively, so it’s super important to focus on research for kids under 12 [78].
A study showed that adding dihydroergotamine (DHE) to the PED clinical care algorithm made its jump from 0% to 37.2%, but even with this change, some providers still preferred not to use it, which meant it wasn't given as much as it should have been [78]. This shows how vital it is to weave treatments into regular care plans to make patient treatment better. The study also saw some nice progress in process measures, like giving IV medication within 90 min [78]. Looking ahead, it's super important to check how these changes affect patient outcomes. We need to look at things like pain reduction and how long folks stay in the hospital. Plus, we should keep working on clinical care algorithms so that there’s less difference in practice and better overall management in the PED.
Conclusion
Effective management of pediatric headaches in emergency departments is critical for improving patient outcomes. Addressing the challenges of accurate diagnosis and treatment variability requires a multidisciplinary approach and ongoing research into innovative therapies. Enhanced training for ED practitioners, coupled with the integration of new diagnostic tools and non-pharmacologic interventions, will facilitate better care for pediatric patients. Future efforts should focus on developing standardized protocols to ensure consistent management practices and improve the overall quality of care in this vulnerable population.
Key References:
Wijeratne T, Wijeratne C, Korajkic N, Bird S, Sales C, Riederer F. Secondary headaches - red and green flags and their significance for diagnostics. eNeurologicalSci [Internet]. 2023 Sep 1 [cited 2024 Sep 20];32:100473. Available from: https://www.sciencedirect.com/science/article/pii/S240565022300031X.
Polese D, Belli A, Esposito D, Evangelisti M, Luchetti A, Di Nardo G, et al. Psychological disorders, adverse childhood experiences and parental psychiatric disorders in children affected by headache: a systematic review. Neuroscience & Biobehavioral Reviews [Internet]. 2022 Sep 1 [cited 2024 Sep 20];140:104798. Available from: https://www.sciencedirect.com/science/article/pii/S0149763422002871.
Abu-Arafeh I. Headache and Psychological Comorbidities: an Appraisal of the Evidence. Journal of Clinical Medicine [Internet]. 2023 Jan [cited 2024 Sep 20];12(7):2683. Available from: https://www.mdpi.com/2077-0383/12/7/2683.
These articles collectively emphasize the complexity of pediatric headache management, highlighting the need for accurate diagnosis, psychological considerations, and multidisciplinary care. Wijeratne et al. (2023) focus on distinguishing secondary headaches using red and green flags, which is critical for preventing misdiagnosis of life-threatening conditions. Polese et al. (2022) and Abu-Arafeh (2023) explore the strong link between pediatric headaches and psychological factors, such as adverse childhood experiences, anxiety, and depression, reinforcing the importance of integrated mental health care. Orr (2024) provides a comprehensive clinical guide on the epidemiology, diagnosis, and treatment of pediatric headaches, supporting evidence-based management strategies.
Declarations
I declare that the work presented in this manuscript is original and has not been submitted in whole or in part, for publication elsewhere. All authors have contributed significantly to the conception, design, execution, and interpretation of the work.
Ethics approval and consent to participate:
Not applicable.
Consent for publication:
Not applicable.
Competing interests
The authors declare no competing interests.
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