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The Problem
“My child is having headaches.”
Common Causes
Migraine
Tension headache
Other Causes
Eyestrain (uncommon cause of headache)
Accommodation difficulty
High refractive error
Increased intracranial pressure
Tumor
Hydrocephalus
Idiopathic intracranial hypertension
KEY FINDINGS
History
Migraine
Usually fairly severe headache
Child stops activities to lie down or go to school nurse
Nausea/vomiting
Prodromal visual symptoms
Sparkling colors, jagged lines, visual field changes
Family history
Tension headache
Often situational (e.g., during school)
Less severe symptoms
Do not stop activities
Eyestrain
Eye fatigue or double vision
Worse when reading
Increased intracranial pressure
Progressive symptoms, more constant
Headache may awaken child from sleep
Nausea, vomiting
Double vision
Transient episodes of vision loss
Examination
Migraine
Normal vision
Normal examination
If seen during headache, may have visual field changes
Eyestrain
Visual acuity usually normal
Increased intracranial pressure
Bulging fontanelle in infant (too young to complain of headache)
Papilledema
Possible sixth nerve palsy
Other cranial nerve palsies
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Headaches are a fairly frequent complaint in children, and most are not a serious problem. However, they may be an early symptom of serious disorders such as an intracranial tumor or idiopathic intracranial hypertension. A careful history and examination are necessary to determine whether additional testing or referral to a pediatric ophthalmologist or neurologist is indicated. If the history is consistent with migraine or tension headache and the examination is otherwise normal, symptomatic treatment may be all that is necessary. If the history or examination suggests the possibility of increased intracranial pressure, then imaging studies and referral to a pediatric neurologist are indicated.

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The eyes themselves are rarely the cause of headache, but an ophthalmological examination may be necessary to rule out this possibility.

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What Shouldn’t Be Missed

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Migraine headaches are not uncommon in children. They may present with an initial complaint of abnormal visual phenomenon (prodrome). Recognition of migraines is important both for treatment and to avoid unnecessary testing. Less commonly, headaches may result from intracranial tumors or other serious disorders. The presence of papilledema indicates the need for prompt evaluation.

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  • 1. Migraine headache. Migraine headaches are more common in children than is often recognized. These may present with specific complaints of eye pain, which may be retro- or periorbital. Classic migraines are accompanied by prodromal syndromes, which are often visual, such as sparkling lights, jagged lines, or visual field defects (Figure 22–1). Most patients develop headaches in association with these phenomena, but the abnormal visual sensations sometimes occur without the headache (acephalgic migraine). The features of the headache, normal eye examination after the symptoms resolve, and the presence of a family history of migraines help in establishing a diagnosis.
  • 2. Tension headache. Tension headaches also occur in children, but are less severe. Patients typically do not specifically complain of eye pain. The headaches tend to occur in specific situations, such as while at school.
  • 3. ...

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