Top 5 Red Flags for Headaches and Migraines Every Parent Should Know

One of the most common complaints in Pediatric Neurology was headaches and migraines. Usually when we hear our child say, “Ow, my head hurts,” or even if we feel that pain coming on ourselves, some of us tend to assume the worst. We jump onto the internet and doom scroll through the worst possible scenarios which would lead to a referral to me in neurology or an extended discussion at their child’s physical.

There is obviously a lot of fear surrounding headaches because we tend to associate that pain with something sinister lurking beneath our skulls so it’s time to talk about the top five red flags when it comes to headaches and migraines and which of them should result in an urgent visit with your provider or a visit to your local Emergency Department.

*Remember that the following is not medical advice and should always be discussed with your provider. These are meant as educational and not medical recommendations*

A headache that resolves after vomiting

Vomiting is not an uncommon finding associated with headaches and migraines. What makes it concerning in a child is if after vomiting, the pain has resolved or the vomiting will not stop and cannot be controlled. This is an automatic emergency room visit IF there has been previous intracranial surgery or confirmed diagnoses such as hydrocephalus. While these findings do not always equal a more serious underlying condition, it does warrant further investigation to ensure that there is not increased pressure building within the brain. In short, if there is something causing swelling, which can lead to pain, the brain will tell the body to help release this pressure by inducing vomiting. If the pain or vomiting is uncontrollable, this would likely result in an emergency room or urgent care visit. It is important to determine whether the nausea and vomiting is simply a feature of the migraine or is it a sign of an underlying condition.

A headache that wakes you from sleep

Many of us have gone to bed with a headache and woken up the next morning with some or little improvement. That wouldn’t concern me as much as pain that is severe enough that it wakes a child up from sleep. While there are some migraine disorders that can present this way without additional comorbidities, it is important to rule out underlying health problems such as increased intracranial pressure, sleep apnea, low blood sugar, or increased blood pressure. This finding would warrant a call to your provider, especially overnight, to evaluate whether a visit to the Emergency Room is needed or if you can wait until the morning to be seen.

Associated personality or behavior changes

One of the biggest red flags, whether it is associated with migraine features or not, is if a parent comes into the clinic concerned that there child is not acting or behaving like themselves. If one of the responses to a provider is along the lines of, “He never used to act this way,” or “This is not my child,” I always go with the parents gut. When we say personality or behavior changes, this is more than a bad day at school. This would present as a consistent pattern of behavior that is atypical for their child. Statements such as these should warrant a thorough evaluation and potential imaging such as a CT or MRI of the brain. Reasoning behind this would be to rule out a neurologic disorder or structural issue within the brain versus a reaction to chronic pain, psychiatric causes, and/or environmental factors.  

Difficulty walking or odd movements associated with the headache

There are migraines that present with features that can be truly terrifying for parents to witness. As providers it is our job to rule out the scary causes to ensure that it is truly a specific type of migraine disorder versus pain caused by an underlying health condition. An example of this is a hemiplegic migraine, which actually causes stroke like symptoms including paralysis on one side of the body. As headaches and migraines are associated with the brain, there can be symptoms that present as other neurological disorders such as this or even seizure-like activity. If your child ever complains of a headache and has any movements that have you concerned for a seizure, or have difficulty walking, this warrants urgent evaluation.

Worsening vision or vision loss

Oddly enough, vision changes are not uncommon when it comes to migraines. And while they can be scary for the patient, they do not always mean we are missing something scary. One of the most interesting ones I learned about is Alice in Wonderland Syndrome. People suffering from this can see objects as appearing smaller or larger than they really are and the world can appear distorted almost as if they were in Wonderland. Some of the common vision features with migraines including narrowing of sight, peripheral vision loss, blurred vision, and even complete loss of vision in one eye. It is important for an immediate eye exam in cases such as these to ensure there is no increased pressure behind the eye or any structural issues that could be impairing the vision versus just a feature of the migraine. Any visual disturbance associated with a headache or migraine should include a vision to a pediatric ophthalmologist.

Now that I have thoroughly terrified you all, let me provide some reassurance. This information is not to scare you, but to give you some insight into what would warrant further investigation should your child be experiencing a headache or migraine. These are not the only red flags, however these are some of the top ones we as providers have in mind to watch out for when we have a child complaining of a headache.

This does not mean that if your child has none of the above issues that you should be brushed aside. Absolutely not. However, there are times when having urgent evaluation is warranted and when you can wait to discuss it with your provider in the office. I would never tell a parent not to call or go with their gut. You as the parent know your child best and if there is something not sitting right with how your child’s headache, then you need to speak up and advocate for your family.