When children have headaches or experience migraine, it is usually not necessary to make a referral to a neurologist right away. Michael K. Sowell, M.D. and Elizabeth S. Doll, M.D., pediatric neurologists at Norton Children’s Neuroscience Institute, affiliated with the UofL School of Medicine, share tips for how to begin treating a patient before making a referral to Norton Children’s Neuroscience Institute.

“A pediatrician often can begin treatment for a child’s headache or migraine attack, which may speed up relief of their symptoms,” said Michael K. Sowell, M.D., child neurologist with Norton Children’s Neuroscience Institute, affiliated with the UofL School of Medicine.

Headache treatment and prevention

According to Dr. Doll, the following steps should be started by the pediatrician upon initial call or visit:

• Acute headache: The patient should be offered an over-the-counter painkiller, such as ibuprofen or acetaminophen.
• Frequent headaches: The pediatrician can begin preventive medication as an early form of headache treatment. Treatment options may include “nutraceuticals” like magnesium oxide, coenzyme Q 10 or riboflavin. Other treatment options may include beta blockers, calcium channel blockers, antidepressants or anti-epileptics. Anti-nausea drugs may be prescribed for children who experience migraine-related nausea and vomiting.
• Lifestyle factors: Check for proper hydration and nutrition; adequate sleep and exercise; limiting stress and screen time. Encourage the family to make modifications as necessary. At times, referral to a pediatric behavioral health specialist may be considered.

When to make a referral

Warning signs may include focal neurologic signs, papilledema, neck stiffness, an immunocompromised state, sudden onset of the worst headache in the patient’s life, personality changes, headache after trauma and headache that is worse with exercise.

Providers should use “SNOOP” to determine if the patient should be referred to Norton Children’s Neuroscience Institute or requires an MRI, although most patients do not need a brain MRI due to low yield.

• The American Headache Society’s “SNOOP” mnemonic helps outline the red flags and warning signs for headaches that would suggest further investigation and/or diagnostic imaging:
• SYSTEMIC SYMPTOMS (fever, weight loss) OR SECONDARY RISK FACTORS (HIV, systemic cancer, rheumatologic disorders)
• NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness or consciousness)
• ONSET: sudden, abrupt or split-second
• OLDER: new onset and progressive headache, especially in middle age/ages 50 and older (not applicable in children)
• PREVIOUS HEADACHE HISTORY: first headache (often excruciating) or different (change in attack frequency, severity or clinical features)