Paediatric headache: migraine, tension-type, and when to escalate

Headache is one of the most common paediatric presentations in Australian general practice. About 75% of adolescents experience headache at least monthly (Headache Australia), and migraine affects roughly 10–15% of school-aged children. The female-to-male ratio shifts from near-equal at school age to around 3:1 by late adolescence as oestrogen cycling begins.

The clinical task in general practice is identifying the small minority with a secondary (dangerous) cause and managing the large majority with primary headache — migraine, tension-type, or a combination. Secondary headaches requiring urgent investigation account for fewer than 2% of paediatric headache presentations without red flags, but the consequences of missing them are severe. Systematic red-flag screening is essential at every consultation.

This article follows the Royal Children’s Hospital Melbourne CPG 2024, eTG neurology module, Headache Australia, and the International Classification of Headache Disorders 3rd edition (ICHD-3).

A. Core clinical — the AU general-practice framework

Classification

Primary paediatric headaches are diagnosed clinically against ICHD-3 criteria once red flags and secondary causes are excluded:

• Migraine without aura (paediatric) — ≥5 attacks lasting 1–72 hours in children (the adult threshold of ≥4 hours does not apply); ≥2 of: bilateral or unilateral (paediatric migraine is commonly bilateral-frontotemporal, not the unilateral pattern typical in adults), pulsating, moderate-to-severe, aggravated by routine activity; plus ≥1 of nausea/vomiting or photo- and phonophobia.
• Migraine with aura — fully reversible focal neurological symptoms, most often visual (scintillating scotoma, fortification), developing over ≥5 minutes and lasting 5–60 minutes.
• Chronic migraine — ≥15 headache days per month for >3 months, with ≥8 fulfilling migraine criteria.
• Tension-type headache (TTH) — bilateral, pressing, mild-to-moderate, not aggravated by activity, without nausea, and with photo- or phonophobia but not both. This is the most common primary headache across the paediatric age range.
• Episodic syndromes associated with migraine — abdominal migraine (recurrent midline abdominal pain 2–72 hours with pallor and anorexia, mean age 7 years); cyclic vomiting syndrome; benign paroxysmal vertigo of childhood.

Red flags — SNNOOP10 plus paediatric-specific

The SNNOOP10 mnemonic (ICHD-3, RCH Melbourne CPG 2024) encompasses: Systemic symptoms or disease; Neoplasm history; Neurological deficit or altered consciousness; Onset sudden (thunderclap); Older age onset; Pattern change or progressive worsening; Positional; Precipitated by Valsalva; Papilloedema; Pregnancy or postpartum; Painful eye with autonomic features; Post-traumatic; Pathology of immune system; Painkiller overuse.

Paediatric-specific additions (RCH 2024, NICE CG150):

• Headache waking the child from sleep, or headache present on waking with vomiting
• Morning vomiting before feeling nauseated (“projectile,” relieved afterwards)
• Progressive worsening over weeks
• Focal neurological signs — limb weakness, ataxia, cranial nerve palsy, diplopia
• Papilloedema on fundoscopy — mandatory at every paediatric headache assessment
• Head tilt (posterior fossa mass or fourth-nerve palsy)
• Deteriorating school performance, behaviour change, growth failure
• Age under 5 years with new-onset headache — primary headache is uncommon this young
• Short stature with arrested or precocious puberty (consider sellar/suprasellar mass)
• Thunderclap onset — peak severity within one minute
• Fever, neck stiffness, photophobia, and non-blanching rash — meningococcal or meningitis

History

A structured headache history includes:

• Character: onset (acute/subacute/chronic/episodic), duration, site, quality, severity, time of day, frequency
• Triggers: sleep deprivation, missed meals, dehydration, screen exposure, stress, menstruation in adolescent girls
• Aura: visual disturbances, paraesthesia, dysarthria — ask specifically; children may not volunteer these
• Associated features: photophobia (retreating to dark room), phonophobia, nausea, vomiting, abdominal pain in younger children (abdominal migraine variant)
• Family history of migraine — positive in ~70% of paediatric migraineurs
• Mood and anxiety screen — comorbid in ~30%; drives chronicity; use age-appropriate tools
• Sleep history — schedule, duration, snoring (screen for OSA as a secondary cause)
• Analgesic use — count days per month; simple analgesics ≥15 days/month or triptans ≥10 days/month for ≥3 months = medication-overuse headache

Examination

• Vital signs including blood pressure — hypertension is a secondary headache cause; measure BP in every child presenting with headache
• Height and weight on percentile charts; head circumference in under-3s
• Fundoscopy is mandatory — papilloedema for raised intracranial pressure; its absence does not rule out early raised ICP
• Cranial nerve examination — pupils, eye movements, facial symmetry, hearing
• Full limb neurological examination — tone, power, reflexes, coordination, gait (heel-toe walk and Romberg)
• Meningism — neck stiffness, Kernig sign, Brudzinski sign
• Skin — neurocutaneous markers (café-au-lait macules in neurofibromatosis; hypopigmented patches in tuberous sclerosis); non-blanching rash
• Visual acuity — Snellen chart in older children; optometry referral when refractive error is suspected

Investigations — red-flag-driven

No imaging if no red flags and the clinical pattern fits migraine or TTH — this is the dominant message from RCH 2024 and NICE CG150. Routine neuroimaging in primary headache with a normal examination has a yield of 0–2% and exposes children to radiation (CT) or requires sedation (MRI in young children).

When red flags are present:

• MRI brain — preferred over CT to avoid ionising radiation; indicated for any red flag, focal neurology, papilloedema, progressive pattern, age under 6, or headache waking the child from sleep
• CT brain — reserved for acute presentations where MRI is not immediately available (suspected subarachnoid haemorrhage, intracranial haemorrhage, acute deterioration)
• Lumbar puncture — suspected meningitis (after excluding mass lesion) or idiopathic intracranial hypertension; measure opening pressure (>25 cm H₂O in children, >28 cm H₂O in obese children per Friedman Neurology 2013, with the child relaxed and in the lateral decubent position)
• Bloods — FBC, U&E, glucose, CRP when infection, metabolic cause, or pre-medication baseline are indicated

B. Treatment — lifestyle first, medication second

Why the lifestyle foundation matters

The CHAMP trial (Powers NEJM 2017) randomised children and adolescents to amitriptyline, topiramate, or placebo for migraine prevention. Both active arms were stopped early for futility. The 50%-reduction-in-headache-days response rate was 52% for amitriptyline, 55% for topiramate, and 61% for placebo. The extraordinary placebo/regression-to-mean effect in paediatric migraine means the non-pharmacological foundation carries most of the preventive benefit.

Lifestyle interventions with strong evidence:

• Regular sleep — consistent wake time, even on weekends; school-age children need 9–11 h, adolescents 8–10 h; both deprivation and weekend oversleeping trigger attacks
• Hydration — adolescents aim for 1.5–2 L of water daily; dehydration is a consistent paediatric trigger
• Regular meals — breakfast is non-negotiable; skipping meals drives glucose and osmotic instability
• Daily aerobic exercise — ≥60 minutes of moderate activity most days; outdoor exercise preferred
• Screen hygiene — structured breaks every 30–45 minutes during homework; no screens 1 hour before bed
• Trigger diary — 4–6 weeks before drawing conclusions; most reported triggers are not reliably reproducible on blinded provocation

Acute treatment

Per RCH Melbourne CPG 2024 and AMH Children’s:

• Paracetamol 15 mg/kg PO (max 1 g per dose) — give early in the attack; level-1 evidence (Damen Paediatrics 2005)
• Ibuprofen 10 mg/kg PO (max 400 mg per dose) — equally effective or marginally superior to paracetamol
• Ondansetron 0.15 mg/kg — when vomiting limits oral absorption; off-label for migraine but standard paediatric emergency practice
• Triptans — second-line when first-line analgesics are inadequate:
  • Rizatriptan oral disintegrating tablet 5–10 mg — TGA-registered ≥6 years; the only triptan with on-label use under 12 in Australia
  • Sumatriptan nasal spray 5–20 mg — TGA-registered ≥12 years
• Rest in a cool, dark, quiet room — single highest-evidence non-pharmacological acute intervention
• Avoid opioids and combination analgesics — they drive medication-overuse headache

Preventive medication

Consider preventive treatment when attacks are disabling (≥4 per month or ≥8 headache days per month) or significantly impact school attendance and function.

Given the CHAMP result, lifestyle and behavioural therapy lead. Pharmacological options when indicated:

• Propranolol 1–2 mg/kg/day in 2–3 divided doses — first-line pharmacological preventive in RCH CPG and eTG; avoid in asthma, depression, or type 1 diabetes
• Topiramate 1–2 mg/kg/day — used off-label below age 12; counsel adolescent girls about teratogenicity and contraception; side effects include cognitive slowing, paraesthesia, and renal stones
• Amitriptyline — not superior to placebo in CHAMP; retains a role where mood comorbidity or TTH phenotype coexists
• Cognitive behavioural therapy (CBT) — Powers JAMA 2013 showed CBT plus amitriptyline achieved ≥50% headache-day reduction in 66% of adolescents with chronic migraine, versus 36% with headache education plus amitriptyline; access via psychologist under a Mental Health Care Plan

Note: Flunarizine is not TGA-registered in Australia and is only available through the Special Access Scheme. CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are not approved for paediatric use in Australia — do not initiate in general practice.

C. Idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is increasingly diagnosed in adolescent girls, particularly those with obesity or recent weight gain. The clinical picture is daily progressive headache, transient visual obscurations (brief greying or blacking of vision), pulsatile tinnitus, and papilloedema on fundoscopy. LP opening pressure is elevated (>25 cm H₂O in children, >28 cm H₂O in obese children per Friedman Neurology 2013) with normal MRI brain/MRV and normal CSF composition.

GP role: refer promptly to ophthalmology and paediatric neurology — vision is at risk from chronic papilloedema-related optic nerve compression. Treatment involves weight reduction where applicable, acetazolamide (PBS Authority Required for IIH), and serial visual field monitoring. Surgery (CSF diversion shunt or optic nerve sheath fenestration) is reserved for fulminant visual loss.

D. Australian operations

MBS items:

• Standard GP consultations: Level B 23, Level C 36, Level D 44
• MRI brain for a child under 16 with unexplained headache and neurological signs — items 63551 / 63556 — a paediatrician or paediatric neurologist request is required for Medicare rebate; GP-ordered paediatric MRI brain is generally not rebated
• CT brain — item 56007 — GP-orderable when clinically indicated
• Mental Health Care Plan — items 2715 / 2717 — access to a psychologist for CBT and biofeedback; evidence-leading treatment for adolescent chronic migraine per Powers JAMA 2013
• GPCCMP (Chronic Conditions Management Plan) 965 / review 967 — for chronic migraine significantly impairing school function; enables allied health referrals (psychology, physiotherapy, dietitian)
• ATSI Health Assessment — item 715 — comprehensive paediatric review opportunity

PBS items:

• Paracetamol, ibuprofen — OTC
• Propranolol — PBS general listing (on-label for hypertension; off-label for paediatric migraine prevention)
• Topiramate — PBS general listing for epilepsy; the migraine-prevention PBS listing applies to adults; off-label in children
• Rizatriptan ODT — PBS general for migraine; TGA on-label ≥6 years
• Sumatriptan nasal spray — PBS general for migraine; TGA on-label ≥12 years
• Amitriptyline — PBS general listing; obtain baseline ECG if dose exceeds 0.5 mg/kg
• Acetazolamide — PBS Authority Required for IIH; specialist initiation

School liaison: a written plan to the school nurse or wellbeing coordinator — outlining access to water, a quiet rest space, permission to take medication and leave class — is a small clinical effort with a large functional return.

E. Special populations

Adolescent girls: migraine prevalence increases after menarche, driven by oestrogen cycling. Menstrual migraine typically occurs in the first 1–3 days of menstruation. Options for menstrual migraine include perimenstrual frovatriptan short-course prophylaxis (specialist) or hormonal manipulation to stabilise the oestrogen drop.

Children under 5: primary headache is uncommon under 5 years; lower the threshold for imaging and paediatric referral at this age.

Medication-overuse headache: any child taking analgesics ≥15 days per month (or triptans ≥10 days/month for ≥3 months) is at risk. Management involves analgesic withdrawal — headache typically worsens in the first week before improving — with a bridging course of an NSAID plus antiemetic, followed by preventive therapy. Counsel families clearly about the withdrawal process.

Children with anxiety or depression: mood disorders are present in ~30% of paediatric migraineurs and drive chronicity. Treating mood and headache in parallel through a Mental Health Care Plan is more effective than treating either alone.

When to escalate

To ED immediately (call 000 or take directly):

• Thunderclap headache — peak severity within one minute
• Focal neurological signs, altered consciousness, or GCS drop
• Fever, neck stiffness, photophobia, and non-blanching rash
• Papilloedema on fundoscopy
• Headache waking the child from sleep with vomiting
• Post-traumatic headache that is worsening

Semi-urgent referral to paediatric neurology:

• Progressive worsening over weeks
• Age under 5 with new-onset persistent headache
• Suspected IIH — papilloedema or typical clinical features
• Abnormal neurological examination
• Three or more preventive medication failures
• Severe chronic migraine not responding to GP-led management

Ophthalmology: confirm papilloedema; assess visual fields when IIH is suspected; refractive error evaluation when visual symptoms accompany headache.

What this article is and is not

This is general health information based on current Australian paediatric headache guidelines — Royal Children’s Hospital Melbourne CPG 2024, eTG neurology, Headache Australia, AMH Children’s, and referenced peer-reviewed trials. It does not constitute personal medical advice and does not create a doctor–patient relationship. Decisions about investigation and treatment are made with your child’s own GP, paediatrician, or neurologist.

For parent-friendly information: Headache Australia — children, HealthDirect — headaches in children, and RCH Kids Health Info.

For an acute medical emergency, call 000 or go directly to your nearest emergency department.

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Sources cited

1. Royal Children’s Hospital Melbourne — Headache CPG 2024
2. Headache Australia — Children and headache
3. ICHD-3 — International Classification of Headache Disorders, 3rd ed. (IHS 2018)
4. eTG complete — Neurology / headache
5. Australian Medicines Handbook Children’s
6. RACGP
7. NICE CG150 — Headaches in over 12s (2021 update)
8. TGA — Sumatriptan, rizatriptan, CGRP information
9. HealthDirect — Headache in children
10. RCH Kids Health Info
11. Powers SW et al. CHAMP trial — NEJM 2017;376:115-24
12. Powers SW et al. CBT for chronic migraine in adolescents — JAMA 2013;310:2622-30
13. Damen L et al. Symptomatic treatment of migraine in children — Paediatrics 2005;116:e295-302
14. Friedman DI et al. Revised diagnostic criteria for pseudotumour cerebri — Neurology 2013;81:1159-65