The Croatian Society of pediatric neurology guidelines for diagnosis and treatment of headaches in children
Authors: Barišić N. , Prpić I. , Lehman I. , Grđan P. , Rešić B. 
Published: November 2024

Headache is one of the most common symptoms in neurology. The Croatian Society of Pediatric Neurology Headache Task Force suggests the following guidelines for evaluation of children with headaches including diagnostic criteria for headache classification (International Classification of Headache Disorders, ICHDII) according to the International Headache Society (IHS), which are based on data analysis of the available literature and treatment principles based on facts and evidence. The goal of the guidelines is good clinical practice. Guidelines are available on the CSPN web page (www.hddn.hlz.hr). According to the IHS classification, headaches are divided into primary and secondary headaches. Migraine, psychogenic or tension headache, trigeminal neuralgia and Horton-Bing’s (cluster) headache are primary headaches. Acute headaches are primary headaches in most cases. Chronic headaches are a large group of frequent or everyday long-lasting headaches (more than 4 hours per day) when compared to shortterm headaches. Every child with headache needs individual approach. The evaluation of a child with headache starts with detailed physical examination (blood pressure measurement included), neurological examination and thorough history. Secondary headache must be excluded, which means that other causes must be sought. Focal neurologic symptoms and signs suggest the presence of secondary headache that needs urgent diagnostic procedure. Headache characteristics that present an indication for urgent neuroradiological examination are intense acute sudden headache in a previously healthy child, acute or chronic headache including migraine and progressive psychogenic headache, positive meningeal signs, focal neurological signs and papilledema of the optic nerve. If neurological examination is normal in a child with recurrent headaches, there is no need for (urgent) neuroradiological diagnostic procedure (brain CT/MRI scans). If brain CT is normal in a child with intense headache, brain MRI has to be done along with lumbar tap and cerebrospinal fluid (CSF) examination in order to exclude subarachnoid hemorrhage or meningoencephalitis. Neuroradiological procedures are absolutely necessary to find the cause of secondary headaches. CSF examination has to be done in a febrile immunocompromised child to confirm or exclude meningitis. Routine EEG is not necessary in a child with headache. It has to be performed if there is the possibility of epileptic seizure or secondary headache (caused by a tumor, head trauma, encephalitis, intracranial hemorrhage or ischemia). EEG changes are neither specific nor pathognomonic for a special cause of headache. When treating headache (after secondary causes have been excluded), the child must be placed in a dark quiet room, and only drugs with known mechanism of action can be prescribed. It is always necessary to ask for parents’ informed consent to treatment with a certain specific drug for a migraine considering the possible side effects and whether the drug is approved by the Croatian Institute of Health Insurance for treating children. Analgesics and nonsteroidal antirheumatics are used in the treatment of acute headache. Acetaminophen is used in analgesic dosage (15-20 mg/kg) and can be repeated in 4 hours. The dosage of ibuprofen is 10 mg/kg up to twice a day. Ondansetron can be prescribed if there is recurrent vomiting accompanied with migraine. Beta blockers are used as prophylactic drugs in patients with migraine as well as antiepileptic drugs and nonpharmacological procedures. Clinical trials have not proved to be of value in pharmacological migraine prophylaxis. Multidisciplinary approach in headache treatment includes parent and children education along with psychosocial approach.