Hospitalized primary headache in children after emergency department evaluation: a retrospective cohort study

To characterize the clinical features, diagnostic evaluation, management, and final diagnoses of children hospitalized for headache following emergency department (ED) evaluation, and to explore factors associated with treatment refractoriness.

We conducted a retrospective cohort study of children aged 4-17 years presenting to a tertiary pediatric ED with headache as the primary complaint who required hospitalization between January 2019 and June 2024. Patients whose headache was clearly attributed to trauma, fever, or a previously identified systemic or neurological disorder were excluded. Final headache diagnoses were established during hospitalization by the pediatric neurology team, using ICHD-3 criteria when applicable. Data included demographics, clinical presentation, diagnostic testing, treatments, and discharge diagnoses. Descriptive analyses were performed, with exploratory comparisons between patients requiring ≤ 2 versus > 2 sequential pharmacologic interventions.

Among 3,646 ED visits for headache, 162 (4.4%) resulted in hospitalization; 30 children (18.5% of admissions) had a final diagnosis of primary headache and constituted the study cohort. Mean age was 12.7 years, and 70.0% were female. Although frontal location and pressure-type pain were the most common presentation features, 76.7% of patients were ultimately diagnosed with migraine or probable migraine. Acute neurological abnormalities were documented in 10.0% of patients. Cranial CT was performed in 63.3% and brain MRI in 23.3%, with no acute intracranial abnormality or secondary cause explaining the headache identified. Intravenous metamizole (dipyrone) was the most frequently used first-line acute therapy, and 70.0% of patients required a second sequential pharmacologic intervention. Among patients diagnosed with migraine or probable migraine, 21.7% met criteria for status migrainosus. No clinical variables were significantly associated with treatment refractoriness.

Hospitalization for primary headache after pediatric ED evaluation was uncommon but identified a clinically severe subgroup, predominantly with migraine-spectrum disorders and frequently requiring escalation of acute treatment. Despite frequent neuroimaging, no acute intracranial abnormality or secondary cause explaining the headache was identified. These findings suggest that more selective imaging strategies may be appropriate in children with a reassuring clinical presentation, although prospective studies are needed to better define predictors of hospitalization, treatment refractoriness, and optimal acute management.