Pediatric Headache: A Practical Approach to Clinical Diagnosis and Management

Headache is among the most common neurological complaints of childhood and adolescence and can substantially impair school attendance and quality of life. A practical approach to the child with headache rests on four tasks: recognizing the primary headache phenotype, screening for the minority of children whose headache is secondary to another disorder, assessing how much the headache is disabling the child, and matching treatment intensity to that disability. Migraine and tension-type headache account for most primary headache presentations, but the trigeminal autonomic cephalalgias and, rarely, painful cranial neuropathies must also be recognized because their management differs fundamentally from that of migraine. Diagnosis is clinical, based on a structured history, assessment of disability, and a careful general and neurological examination; red flags should prompt reassessment and risk stratification rather than reflexive neuroimaging, and in a child with a typical primary headache phenotype and a normal examination, routine imaging, laboratory testing, or electroencephalography is generally unnecessary. Management is multimodal: education and lifestyle measures form the foundation of care; acute treatment uses evidence-based, age-appropriate analgesics and triptans; and preventive treatment is reserved for children with substantial headache-related disability, bearing in mind the unusually high placebo response documented in pediatric migraine prevention trials. Several calcitonin gene-related peptide-targeted and device-based therapies have emerged for pediatric migraine since 2024, though pediatric evidence and regulatory status vary substantially by therapy. Tension-type headache and the trigeminal autonomic cephalalgias require separate diagnostic and therapeutic consideration, and treatment of the latter reflects evidence largely extrapolated from adults and case series, rather than controlled pediatric trials. This review provides a practical, evidence-based framework for the clinical diagnosis and management of pediatric headache for the general clinician.