- Most headaches in children are benign.
- Headaches can be classified as primary or secondary
- Brain tumor headaches in children are associated with neurologic findings such as papilledema, ataxia, and weakness in 85% of cases within 8 weeks of onset, and in virtually all cases by 24 weeks
- Pseudotumor cerebri causes headache in the absence of a mass lesion.
Headaches are common in childhood. As many as 82% of children experience a headache by the age of 15 years.1,2 Although they usually do not result from serious disease, headaches are sometimes the manifestation of life-threatening illness. It is incumbent on the emergency physician to distinguish those headaches that result from benign, self-limited processes from those that can result in serious morbidity or mortality.
Headaches can be classified as primary or secondary. Primary headaches include migraine, tension-type, and cluster headaches, and are based on criteria defined by the International Headache Society and the International Classification of Headache Disorders.3 Secondary headaches have identifiable etiologies based on history and physical examination. These include headaches attributed to head or neck trauma, infection, a vascular disorder such as bleed or stroke, a nonvascular intracranial disorder such as elevated intracranial pressure or a neoplasm, or a toxic substance such as carbon monoxide. Facial pain, sinus, and dental problems can also cause headaches. Some patients with psychiatric disorders will complain of headache.3 The brain itself is not sensitive to pain, but there are pain-sensitive structures in the skin, the muscles, the vascular sinuses, the intracranial blood vessels, and the meninges at the base of the brain. Inflammation, dilation, irritation, and displacement of the pain-sensitive areas can result in a headache.
The evaluation of a child for a headache includes information on the headache history. Based on this information, the headache can be classified as acute (sudden, first), acute and recurrent (episodic), chronic and progressive (steadily worsening), or chronic and nonprogressive.1,4 One way to help determine headache etiology is demonstrated in Table 56–1.
Table 56-1. Headache Etiology
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Table 56-1. Headache Etiology
Sinusitis, otitis, viral infection: flu
Systemic infection: flu, meningitis
Idiopathic intracranial hypertension
Space occupying lesion (tumor, abscess, hemorrhage, hydrocephalus)
Psychiatric (depression, school phobia)
Dental abscess, TMJ
Exertional, first migraine
The following information should be obtained: age at onset, frequency and duration (minutes, days), time of onset (day, night, schooldays only), location (frontal, temporal, occipital), quality of pain (stabbing, pressure, pounding), associated symptoms (nausea/vomiting, photophobia), warning signs or aura (blurred vision, vertigo, nausea, weakness), precipitating factors (stress, coughing, certain foods), relieving factors (sleep), recent trauma, change in school or home environment, response to treatment at home, and family history of migraines.1,4
The physical evaluation includes general appearance, ...