Headaches in children under 16 years - NICE guidance - suspected neurological conditions - recognition and referral

Headaches in children

Summary points from NICE guidance relating to headaches in children are:

For children 12 years or over then see linked item.

Headaches in children under 12 years

Refer immediately children aged under 12 years with headache for same-day assessment, according to local pathways, if they have any one of the following:

• headache that wakes them at night
• headache that is present on awakening in the morning
• headache that progressively worsens
• headache triggered or aggravated by coughing, sneezing or bending down
• headache with fever and features of meningism
• headache associated with vomiting
• headache associated with ataxia
• headache associated with change in conscious level or pervasive lethargy
• headache occurring within 5 days of a head injury
• headache associated with squint or failure of upward gaze ('sunsetting').

Headaches in children under 4 years

• refer urgently all children aged under 4 years with headache for neurological assessment.

Recurrent headaches and migraines

• perform or request fundoscopy for all children with recurrent headache and refer urgently for neurological assessment if there are abnormalities. For all children with recurrent headache:
  • be aware that hypertension might be the cause
  • measure the child's blood pressure and check the measurement against blood pressure reference ranges adjusted for age and height
  • refer children if headaches are consistently worsened by upright posture and relieved by lying down

Do not routinely refer children with migraine unless it is affecting their school life, social life or family activities, or they have one of the features listed above.

Be aware that emotional stress is a strong trigger of migraine and chronic, daily headache in children. Ask the child and their parent or carer about specific learning problems, bullying at school and stress in the family.

Ask about analgesic use in children with recurrent headache to ensure that medicine use is not excessive and to assess the likelihood of medication overuse headache.

Reference:

• NICE (May 2019). Suspected neurological conditions: recognition and referral