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Headaches in Children and young People
CLINICAL GUIDELINES
Register No: 14037
Status: Public
Developed in response to:
Contributes to CQC Outcome number:
Guideline Review
4
Consulted With
Alison Cuthbertson/
Miss Rao
Mahesh Babu
Manas Datta
Aloke Agrawal
Muhammed Ottayil
Sharmila Nambiar
Sharon Lim
Ahmed Hassan
Brian McConville
Mel Hodge
Andrea Stanley
Sarah Moon
Professionally Approved By
Post/Committee/Group
Clinical Director for Women’s, Children’s and
Sexual Health Directorate
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Lead Nurse
Senior Sister, Phoenix Ward
Clinical Facilitator Children’s Acute Care
Specialist Midwife Guidelines and Audit
Date
November
2014
November
2014
Dr Ottayil Consultant Paediatrician with special
interest in Neurology
Version Number
Issuing Directorate
Ratified by:
Ratified on:
Executive Management Board Sign Off Date
Implementation Date
Next Review Date
Author/Contact for Information
Policy to be followed by (target staff)
Distribution Method
Related Trust Policies (to be read in conjunction
with)
Document Review History
Version Number
Reviewed by
1.0
Victoria Machell
1.0
Children’s and Young People Service
DRAG Chairmans Action
23rd November 2014
December 2014
23rd November 2014
November 2017
Victoria Machell, Paediatric Nurse
All Clinicians
Hard copies on ward
Intranet & website
04072 Hand hygiene
04064 Safeguarding Children
Children’s Early Warning Tool (CEWT)
Review Date
23rd November 2014
1
Index
1
Purpose
2
Equality and Diversity
3
Definitions
4
Assessment
5
Diagnosis
6
Management
7
Staff Training
8
Audit and Monitoring
9
Communication
10
References
Appendix A – Headache Algorithm
2
1.0
Purpose
1.1
To Promote Best practice in the Diagnosis and Treatment of Headaches. Following
the NICE Guidelines
1.2
To ensure that all children cared for by Mid Essex Hospital Services NHS Trust are
treated using best practice
1.3
To ensure that each child is listened to and their rights respected
1.4
To evaluate the Child who presents with Headache and consider the need for further
treatment or referral
2.0
Equality and Diversity
Mid Essex Hospital Trust is committed to the provision of a service that is fair,
accessible and meets the needs of all individuals.
3.0
Definitions
Headache disorders have 2 main classifications, these are Primary and Secondary
type.
3.1
Primary Headaches
These are the most common and are categorised as:
 Tension-type headache
 Migraine
 Cluster headache
3.2
Secondary Headaches
These are caused by underlying disorders such as:
 Medication overuse
 Giant Cell Arthritis
 Raised Intercranial Pressure
 Infection
4.0
Assesment
4.1
Children who present with headaches who have any of the following features require
a consideration for further investigation and or referral to a specialist.
 Worsening headache with Fever
 Sudden onset with maximum intensity reached within 5 minutes
 New-onset neurological deficit
 New-onset cognitive dysfunction
 Change in personality
 Impaired level of consciousness
 Recent head trauma (within 3 months)
 Headaches triggered by coughing, sneezing or breathing through a blocked
nose
 Headaches triggered by exercise
 Orthostatic headache (triggered by changes in posture)
 Substantial changes in characteristics of headaches
 Compromised immunity
 History of malignancy
3


History of brain malignancy or metastasise brain malignancy
Vomiting without obvious cause
4.2
Consider Headache Diary for a minimum of 8 weeks asking the patient or family to
record frequency, duration, severity of the headaches and any associated symptoms.
Ask them to also note any medication used to relieve the headache. If appropriate ask
them to note the relationship between headaches and the menstruation cycle.
5.0
Diagnosis
5.1
Tension type Headaches
Table Diagnosis of tension-type headache, migraine and cluster headache
Headache Tension-type
feature
headache
Migraine (with or without Cluster headache
aura)
Pain
location1
Bilateral
Unilateral or bilateral
Unilateral (around the eye,
above the eye and along
the side of the head/face)
Pain
quality
Pressing/tightening
(non-pulsating)
Pulsating (throbbing or
banging in young people
aged 12–17 years)
Variable (can be sharp,
boring, burning, throbbing
or tightening)
Pain
intensity
Mild or moderate
Moderate or severe
Severe or very severe
Effect on
activities
Not aggravated by
Aggravated by, or causes
routine activities of daily avoidance of, routine
living
activities of daily living
Other
None
symptoms
Unusual sensitivity to light
and/or sound or nausea
and/or vomiting
Restlessness or agitation
On the same side as the
headache:

Aura
2
Symptoms can occur with or 
without headache and:
red and/or watery
eye
nasal congestion
and/or runny nose

are fully reversible


develop over at least
5 minutes

forehead and facial
sweating

last 5−60 minutes.

constricted pupil
and/or drooping eyelid
swollen eyelid
Typical aura symptoms
include visual symptoms
such as flickering lights,
spots or lines and/or partial
loss of vision; sensory
4
symptoms such as
numbness and/or pins and
needles; and/or speech
disturbance.
Duration of 30 minutes–continuous 4–72 hours in adults
15–180 minutes
headache
1–72 hours in young people
aged 12–17 years
Frequency < 15 days ≥ 15 days
of
per month per month
headache
for more
than
3 months
Diagnosis Episodic
tensiontype
headache
5.2
< 15 days per ≥ 15 days per
month
month for
more than
3 months
Chronic
Episodic
tensionmigraine
type
(with or
headache 5 without
aura)
1 every
other day to
8 per day3,
with
remission4
> 1 month
Chronic
Episodic
migraine 6
cluster
(with or
headache
without aura)
1 every other
day to 8 per
day3, with a
continuous
remission4
<1 month in a
12-month
period
Chronic
cluster
headache
Migraine Aura
Aura should be suspected in people with neurological symptoms that are fully
reversible and develop gradually and last for between 5 and 60 minutes.
5.2.1 Diagnosis of migraine with aura patients with or without headache that meet one or
more of the typical symptoms which are:
 Visual symptoms that may be positive e.g. flickering lights, spots or lines and or
negative e.g. partial loss of vision.
 Sensory symptoms that may be positive e.g. pins and needles or negative e.g.
numbness
 Speech disturbance
5.2.2 Further investigation and referral may be considered in children who present with
atypical symptoms such as motor weakness or double vision or visual disturbance
affecting one eye or poor balance or decreased level of consciousness.
5.3
Menstrual related Headaches
These types of headaches should be suspected in girls whose migraine occurs
between 2 days before and 3 days after the start of the menstrual cycle in at least 2
out of 3 cycles. Diagnosis of this is best done using a headache diary.
5.4
Medication overuse
5
Be aware of children whose headaches develop or worsen while they are taking the
following drugs for 3 or more months.
Triptans, opioids, ergots or combination analgesic medications on 10 days per month
or Paracetamol, aspirin or and NSAID, either alone or in combination on 15 days per
month or more.
6.0
Management
6.1
Using a headache diary to record frequency, duration and severity of headaches. Use
of the diary should also monitor effectiveness of interventions and form a basis for
discussion.
6.2
Do not refer people diagnosed with tension-type headache, migraine, cluster
headache or medication overuse headache for neuroimaging solely for reassurance.
6.3
written and oral information about headache disorders including information about
support organisations much be given to families and young people.
6.4
Consider paracetamol, and /or NSAID for tension type headaches. Do not offer
opioids for the acute treatment of tension type headaches.
6.5
Consider nasal triptan for children over 12 years. Children under 12 use NSAIDS and
paracetamol. Consider an anti-emetic in addition to other acute treatment of migraine
even if nausea and vomiting are not present.
7.0
Staff Training
7.1
All medical and nursing staff are to ensure that their knowledge, competencies and
skills are up to date in order to complete their portfolio and appraisal.
7.2
During induction all staff will receive instruction on current policies and guidelines and
how to access them.
7.3
Staff will regularly receive updated guidelines to read.
8.0
Audit and Monitoring
8.1
Where a Patient’s notes have demonstrated that the appropriate action has not been
taken then a ‘DATIX’ form is to be completed. This will highlight further staff training
needs.
8.2
A quarterly DATIX audit will be examined by the Lead Nurse and the clinical director
and risk lead for CYP
8.3
Where a child’s notes have demonstrated that the appropriate action has not been
taken a ‘risk event form’ is to be completed. This will address any further training
needs for staff that require updating.
8.4
Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy, the Women’s and Children’s
Directorate annual audit work plan and the NHSLA/CNST requirements. The Audit
Lead in liaison with the Risk Management Group will identify a lead for the audit.
6
8.5
The findings of the audit will be reported to and approved by the Risk Management
Group and an action plan with named leads and timescales will be developed to
address any identified deficiencies. Performance against the action plan will be
monitored by this group at subsequent meetings.
8.6
Key findings and learning points from the audit will be submitted to the Patient Safety
Group within the integrated learning report.
8.7
Key findings and learning points will be disseminated to relevant staff.
9.0
Communication
9.1
Ratified guidelines will be uploaded to the intranet and website.
9.2
It is the responsibility of the author to ensure that all clinical staff working with children
are individually notified by email
10.0
References
www.nice.org.uk
www.uhbristol.nhs.uk/
Appendix A
headaches
algorithm.pdf
7