Emergent evaluation of headache in children
- Christopher King, MD, FACEP
Christopher King, MD, FACEP
- Professor and Chair of Emergency Medicine
- Albany Medical College
- Section Editors
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Marc C Patterson, MD, FRACP
Marc C Patterson, MD, FRACP
- Section Editor — Pediatric Neurology
- Professor of Neurology, Pediatrics, and Medical Genetics
- Chair, Division of Child and Adolescent Neurology
- Mayo Clinic College of Medicine
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will review the emergent evaluation of children with headaches who do not have predisposing conditions.
Children with headaches who present nonurgently and those with well-established histories of migraine or tension-type headaches are discussed separately. (See "Headache in children: Approach to evaluation and general management strategies" and "Pathophysiology, clinical features, and diagnosis of migraine in children" and "Tension-type headache in children".)
Although headaches occur frequently among children, most do not seek medical attention [1,2]. Caretakers may bring children to the emergency department or primary care provider for headaches that are more severe or have not responded to nonprescription medications. In one retrospective series from a busy children's hospital emergency department, 1 percent of visits were for a chief complaint of headache .
The terms "primary" and "secondary" may be used to describe headaches. Primary headaches (ie, migraine, tension-type, or cluster headaches) are typically self-limited and diagnosed based on symptom profiles and patterns of headache attacks. Secondary headaches have identifiable etiologies. Although the vast majority of secondary headaches in children have benign etiologies (ie, viral infections), the goal of the emergent evaluation of children with headaches is to identify as a first priority those with serious or life-threatening causes . In most patients, this task can be accomplished with a careful history and physical examination and occasional selected ancillary testing.
Headache can be the symptom of life-threatening complications for children with various underlying conditions (ie, those with immunodeficiencies who develop opportunistic infections or patients with ventriculoperitoneal shunts that malfunction causing obstruction) (see "Hydrocephalus in children: Management and prognosis", section on 'Complications'). Evaluation of headache in these children (which is often guided by specific protocols that include neuroimaging and consultation with a specialist) will not be discussed here.
- Anttila P, Metsähonkala L, Sillanpää M. Long-term trends in the incidence of headache in Finnish schoolchildren. Pediatrics 2006; 117:e1197.
- van der Wouden JC, van der Pas P, Bruijnzeels MA, et al. Headache in children in Dutch general practice. Cephalalgia 1999; 19:147.
- Burton LJ, Quinn B, Pratt-Cheney JL, Pourani M. Headache etiology in a pediatric emergency department. Pediatr Emerg Care 1997; 13:1.
- Kabbouche MA, Linder SL. Acute treatment of pediatric headache in the emergency department and inpatient settings. Pediatr Ann 2005; 34:466.
- Lewis DW, Qureshi F. Acute headache in children and adolescents presenting to the emergency department. Headache 2000; 40:200.
- Kan L, Nagelberg J, Maytal J. Headaches in a pediatric emergency department: etiology, imaging, and treatment. Headache 2000; 40:25.
- Locker TE, Thompson C, Rylance J, Mason SM. The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department. Headache 2006; 46:954.
- Hafidh MA, Keogh I, Walsh RM, et al. Otogenic intracranial complications. a 7-year retrospective review. Am J Otolaryngol 2006; 27:390.
- Corson MA, Postlethwaite KP, Seymour RA. Are dental infections a cause of brain abscess? Case report and review of the literature. Oral Dis 2001; 7:61.
- The epidemiology of headache among children with brain tumor. Headache in children with brain tumors. The Childhood Brain Tumor Consortium. J Neurooncol 1991; 10:31.
- Dobrovoljac M, Hengartner H, Boltshauser E, Grotzer MA. Delay in the diagnosis of paediatric brain tumours. Eur J Pediatr 2002; 161:663.
- Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features. Am J Dis Child 1982; 136:121.
- Al-Jarallah A, Al-Rifai MT, Riela AR, Roach ES. Nontraumatic brain hemorrhage in children: etiology and presentation. J Child Neurol 2000; 15:284.
- Hampson NB, Hampson LA. Characteristics of headache associated with acute carbon monoxide poisoning. Headache 2002; 42:220.
- Jones BV, Egelhoff JC, Patterson RJ. Hypertensive encephalopathy in children. AJNR Am J Neuroradiol 1997; 18:101.
- Pavlakis SG, Frank Y, Chusid R. Hypertensive encephalopathy, reversible occipitoparietal encephalopathy, or reversible posterior leukoencephalopathy: three names for an old syndrome. J Child Neurol 1999; 14:277.
- Pham TH, Moir C, Thompson GB, et al. Pheochromocytoma and paraganglioma in children: a review of medical and surgical management at a tertiary care center. Pediatrics 2006; 118:1109.
- Schobitz E, Qureshi F, Lewis D. Pediatric headaches in the emergency department. Curr Pain Headache Rep 2006; 10:391.
- Anttila P, Metsähonkala L, Helenius H, Sillanpää M. Predisposing and provoking factors in childhood headache. Headache 2000; 40:351.
- Anttila P. Tension-type headache in childhood and adolescence. Lancet Neurol 2006; 5:268.
- Anttila P, Metsähonkala L, Aromaa M, et al. Determinants of tension-type headache in children. Cephalalgia 2002; 22:401.
- Bonjardim LR, Gaviao MB, Carmagnani FG, et al. Signs and symptoms of temporomandibular joint dysfunction in children with primary dentition. J Clin Pediatr Dent 2003; 28:53.
- Farsi NM. Symptoms and signs of temporomandibular disorders and oral parafunctions among Saudi children. J Oral Rehabil 2003; 30:1200.
- Wilne SH, Ferris RC, Nathwani A, Kennedy CR. The presenting features of brain tumours: a review of 200 cases. Arch Dis Child 2006; 91:502.
- Massano D, Julliand S, Kanagarajah L, et al. Headache with focal neurologic signs in children at the emergency department. J Pediatr 2014; 165:376.
- American College of Radiology. ACR appropriateness criteria. Headache - child. Available at http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/HeadacheChild.pdf. Accessed August 6, 2012.
- Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24 Suppl 1:9.
- Life-threatening conditions
- - Infection
- - Tumor
- - Intracranial hemorrhage
- - Carbon monoxide poisoning
- - Hypertension
- Common conditions
- - Infection
- - Migraine
- - Tension-type headache
- Other conditions
- - Temporomandibular joint dysfunction
- - Idiopathic intracranial hypertension
- - Cluster headaches
- - Headache characteristics
- - Associated symptoms
- - Past medical history
- Physical examination
- Neurologic examination
- Ancillary studies
- - Neuroimaging
- - Lumbar puncture
- - Blood testing
- ALGORITHMIC APPROACH
- History of chronic or recurrent headaches
- Normal neurologic examination
- - Fever
- - No fever
- Focal neurologic examination
- - CT scan abnormal
- - CT scan normal
- INFORMATION FOR PATIENTS