Pediatric Headache Master Intake Form

Joyce Miller, DC, PhD
Retired professor AECC University College,
Visiting professor Health Sciences University, Bournemouth, UK
Minneapolis, MN and Bournemouth, UK
Email: yukonmillerjm@gmail.com

Introduction: A modular system for pediatric headache evaluation was introduced in 2022 consisting of a separate questionnaire, history, and physical exam form.¹ While effective, the clinical landscape has evolved. The rise in recognized autonomic dysfunction, the persistence of regional neuroborreliosis, and the increasing prevalence of pressure-related pathologies in adolescents necessitate a more integrated approach. This updated 2-page Pediatric Headache Master Form consolidates those three instruments while expanding the diagnostic net for secondary headaches.

The Drive for Consolidation: Clinician efficiency is paramount. By merging three separate documents into one, the author has reduced “form fatigue” and ensures that the transition from patient-reported history to objective clinical exam is seamless. This consolidation ensures that critical links—such as the relationship between a toddler’s “periodic syndrome” and a teenager’s current migraine frequency—are not lost in fragmented paperwork.^2,3

Expanding the Differential; Gravity and Pressure: The 2025 update places a heavy emphasis on “gravity-dependent” symptoms. Since 2021, our understanding of the following has become essential for the general pediatrician:

• Orthostatic Headaches & CSF Dynamics: The form now includes specific “time-to-relief” metrics to screen for Spontaneous Intracranial Hypotension (SIH) and CSF leaks.⁴
• Adolescent Pressure Headaches: There are added markers for Idiopathic Intracranial Hypertension (IIH), which is increasingly observed in the teenage population. The inclusion of pulsatile tinnitus and “whooshing” ear sounds serves as a critical red flag for this demographic.^5,6
• POTS & Autonomic Integration: With the increased prevalence of Postural Orthostatic Tachycardia Syndrome (POTS), the form now mandates orthostatic vital signs, linking “coat-hanger” neck pain to autonomic instability.⁷

Infectious & Mechanical Updates: The master form addresses the “migratory” nature of pain—a hallmark of Neuroborreliosis (Lyme Disease). By asking about shifting joint pain and radiculoneuritis alongside the headache history, clinicians can better identify Bannwarth’s Syndrome. Bannwarth’s Syndrome, or lymphocytic meningoradiculitis, is a severe neurological form of Lyme disease, characterized by intense, radiating nerve pain (radiculopathy), cranial nerve palsies (especially facial), and inflammation in the cerebrospinal fluid (CSF). Furthermore, the author has integrated a postural screen (Upper Crossed Syndrome) to address the mechanical “tech neck” prevalent in school-aged children.⁸

Expanding the Migraine Spectrum; Hormones & Auras: The updated Master Form now accounts for the hormonal fluctuations of adolescence by including specific screening for menstrual migraines. Furthermore, the history section has been nuanced to differentiate between typical visual auras and more complex sensory or auditory hallucinations, ensuring a higher sensitivity for ICHD-3 classification.^9,10

Neuromusculoskeletal & Mechanical Differentiation: To rule out mechanical triggers, the form now includes a targeted Neuromusculoskeletal Exam. This addresses the “tech-neck” epidemic by screening for:

• Upper Crossed Syndrome: Identifying the imbalance between tight pectorals/upper trapezius and weak deep neck flexors.¹¹
• Cervicogenic Markers: Evaluating the upper cervical spine (C0-C3) for segmental dysfunction that frequently mimics or triggers primary headaches.¹²
• TMJ & Cranial Nerve Integrity: Ensuring that jaw dysfunction or subtle cranial nerve deficits aren’t overlooked in the search for primary headache causes.¹³

Conclusion: While migraine and tension-type headaches remain the most common presentations, the “Master Form” ensures that the pediatrician is equipped to identify the pathological outliers. This tool provides a comprehensive, high-yield roadmap for the modern pediatric headache encounter.

Click here to download a .png of the PEDIATRIC HEADACHE MASTER INTAKE FORM
Click here to download a .png of the CLINICAL HEADACHE EXAMINATION (Provider Use Only)

References:

1. Weber S. 2022. Pediatric headache questionnaire, exam and history forms for the chiropractor. Journal of Clinical Chiropractic Pediatrics; 21(1)1871-5.

2. Weber S. 2021. Headaches in children: Part 1. The changing phenotypes of migraine headache in infants, children and adolescents. Journal of Clinical Chiropractic Pediatrics; 20(1)1747-56.

3. Weber S. 2021. Headaches in children: Part 2. The changing phenotypes of headaches in children. Journal of Clinical Chiropractic Pediatrics; 20(1)1802-13.

4. Kim MJ, Farrell J. Orthostatic Hypotension: A Practical Approach. Am Fam Physician. 2022;105(1):39-49. Erratum in: Am Fam Physician. 2022;106(4):365.

5. Kranz PG, Gray L, Malinzak MD, Amrhein TJ. Spontaneous Intracranial Hypotension: Pathogenesis, Diagnosis, and Treatment. Neuroimaging Clin N Am. 2019;29(4):581-594.

6. Wang MTM, Bhatti MT, Danesh-Meyer HV. Idiopathic intracranial hypertension: Pathophysiology, diagnosis and management. J Clin Neurosci. 2022;95:172-179.

7. Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. J Intern Med. 2019;285(4):352-366.

8. Krawczuk K, Czupryna P, Pancewicz S, Oldak E, Król M, Moniuszko-Malinowska A. Comparison of Neuroborreliosis Between Children and Adults. Pediatr Infect Dis J. 2020;39(1):7-11.

9. Rothner AD, Parikh S. Migraine Variants or Episodic Syndromes That May Be Associated With Migraine and Other Unusual Pediatric Headache Syndromes. Headache. 2016 Jan;56(1):206-14. doi: 10.1111/head.12750. Erratum in: Headache. 2016 Apr;56(4):820.

10. Anarte-Lazo E, Carvalho GF, Schwarz A, Luedtke K, Falla D. Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2021;22(1):755.

11. Chang MC, Choo YJ, Hong K, Boudier-Revéret M, Yang S. Treatment of Upper Crossed Syndrome: A Narrative Systematic Review. Healthcare. 2023;11(16):2328.

12. Usen A, Demiroz Gunduz M. Cervicogenic headache in forward head posture: frequency and associated factors in a cross-sectional study. J Oral Facial Pain Headache. 2025;39(3):191-199.

13. Romero-Reyes M, Bassiur JP. Temporomandibular Disorders, Bruxism and Headaches. Neurol Clin. 2024;42(2):573-584.