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Headache is a common condition in children and adolescents. Patients can be hospitalized primarily for headaches or develop headaches during their hospital stay. In either situation, it is important to determine whether the headache represents a primary headache disorder, such as migraine or tension headache, or a secondary disorder resulting from potentially serious intracranial or systemic processes (Table 119-1).

TABLE 119-1International Headache Society Classification of Headache Disorders

Epidemiologic studies in large cohorts of children reveal estimated 1-year prevalence rates of 6% to 20% for migraine and 11% to 18% for tension headache.1-7 In general, post-pubertal girls have the highest prevalence rates of both migraine and tension headache. The most recent classification criteria established by the International Headache Society (IHS) in 20138 provide a detailed classification of headaches in children.


Head pain (cephalgia) is a symptom, and the diagnosis of a headache disorder or migraine is a diagnosis of exclusion. Evaluation of headache consists chiefly of a detailed history and thorough physical examination. Any abnormalities on neurologic examination in a previously healthy child or changes from neurologic baseline in a child with previous abnormalities warrant expeditious evaluation. In the absence of worrisome symptoms and abnormalities in the physical (including neurologic) examination, the majority of headaches in children are not caused by serious pathology. The physician should consider the following key questions during the evaluation:

  • Are there any warning signs of symptoms suggesting increased intracranial pressure (ICP) or focal neurologic abnormalities?

  • Do the symptoms fit into the pattern of a typical headache syndrome?

  • Are there any predisposing factors to secondary headaches such as a ventriculoperitoneal (VP) shunt?

Although the majority of headaches in children do not represent life-threatening emergencies, the pain experienced by the child and the ensuing anxiety of the family can be great. Once a patient with headache is deemed stable and relevant secondary causes have been considered ...

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