Pediatric Headache in Emergency Medicine Clinical Presentation

A thorough history should be obtained in any child presenting to the ED with a headache. The history should describe headache onset, duration, severity, and associated symptoms. A family history of migraines may be helpful in clarifying the diagnosis. A medication history should also be sought.

• Migraine headache overview

  • Because a migraine headache can be classified into several types, symptoms vary depending on the type. Many children with migraines have a previous history of motion sickness, paroxysmal dizziness, or vertigo. The prevalence of migraines is 10.2% in children and 28% in older adolescents.^{[4, 5]} Approximately 60% of all children with migraines are male. Nearly 70% of pediatric patients have a family history of migraine headache. Clinicians should suspect migraine headache in any child who presents with recurrent episodes of incapacitating headaches.
  • Some authors believe that early diagnosis and prompt initiation of optimal treatments (both abortive and preventative) will lead to better treatment outcomes and prognosis and less disability for children and adolescents with migraine.^[6]
  • A possible relationship exists between children who have cyclic vomiting syndrome and migraine headache. A genetic predisposition also appears to exist for patients with cyclic vomiting syndrome and their family members to develop migraine headaches. Patients with cyclic vomiting syndrome, their mothers, and grandmothers may have a prevalence of migraine headache that is about twice that of the general population.
  • Many children with migraine will have some type of premonitory symptoms before the onset of headache. Some of these premonitory symptoms include irritability, fatigue, and changes in facial expression.^[7] The recognition of these subtle premonitory symptoms is helpful in the initiation of abortive therapy.
  • Classic migraine: Patients have a sharply defined headache that is preceded by motor or sensory disturbances, such as blurred vision, floaters crossing the visual field, or transient muscle weakness.
  • Adolescent and adult patients with migraine with aura are thought to be at a higher risk for ischemic stroke, and this risk is magnified among women, patients younger than 45 years of age, smokers, and those using oral contraceptives.^[8]
  • Common migraine: The headache is often less sharp and well defined. No preceding motor or sensory disturbance occurs. This type of migraine is observed more often in children.
  • Complicated migraine: In patients with complicated migraine, focal or diffuse neurologic deficits may occur with the headache. The 4 types of complicated migraine are as follows:
    • Hemiplegic or hemisensory migraine: The headache is accompanied by unilateral motor weakness or sensory disturbance (eg, paresthesias) that may persist for several hours after the headache has subsided.
    • Basilar migraine: The pathogenesis of basilar migraine involves vasoconstriction of the basilar and posterior cerebral arteries. This results in an occipital headache, as well as diplopia, vertigo, tinnitus, or ataxia.
    • Ophthalmoplegic migraine: In addition to a unilateral frontal headache, patients have an ipsilateral third nerve palsy and reversible monocular blindness. This type of migraine is rare in children.
    • Acute confusional states: Acute confusional states are an unusual type of migraine headache and are characterized by sudden onset of confusion, unresponsiveness, memory disturbances, disorientation, and dysarthria. This type of migraine headache is thought to be more common in boys.
  • Cluster headache: Headaches occur in groups or clusters. Nasal discharge, congestion, and a watery red eye are present on the same side of the head as the headache. Cluster headaches often awake a patient from sleep and most often occur in adolescents.
  • The diagnosis of migraine can be made if 3 of the following 6 symptoms are present:
    • Preceding motor, sensory, or vertiginous symptoms
    • Throbbing or pounding pain
    • Pain localizes to one side of the head
    • Associated nausea, vomiting, or abdominal pain
    • Sleep alleviates the pain
    • Family history of migraine
• Tension headache: Tension headaches are common in children. Distinguishing tension headache from migraine headache may be difficult, as many children with migraine headache also complain of neck pain. Distinguishing characteristics of tension headaches include the following:

  • They occur during times of obvious stress.
  • They involve the neck and occiput.
  • Pain is continuous.
  • No nausea, vomiting, or abdominal pain occurs.
  • Family history of migraine is less likely.
• Sinus headache

  • Recurrent headaches occur in approximately 15% of children with sinusitis.
  • These patients complain of a throbbing headache that is worse in the morning or that occurs at the same time each day.
  • The pain may vary with changes in head position.
  • With ethmoid disease, pain may be referred to behind the ipsilateral eye.
  • With frontal sinusitis, pain may occur just above the inner canthi of both eyes.
  • A history of nasal discharge, congestion, and cough lasting more than 10 days is usually given.
  • Fever may be present.
• Head trauma

  • Headaches frequently follow closed-head trauma.
  • The headache may appear acutely or be present for months after the initial injury.
  • Acutely, the patient may complain of headache shortly after the injury, which may worsen and be accompanied by vomiting, lethargy, or seizures; these may be the earliest symptoms of an intracranial hemorrhage.
  • In chronic cases, headache, dizziness, and personality changes may be present for months after the initial injury.
  • Headache is a key feature of the postconcussive syndrome.
• Intracranial masses: Distinguishing intracranial causes from extracranial causes of headache may be difficult. Patients with intracranial masses may complain of pain localized to the region of the mass. However, if a diffuse rise in intracranial pressure exists, the headache may be generalized. Some distinguishing historical features of intracranial masses include the following:

  • Severe occipital headache, sneezing, coughing, any Valsalva maneuver, or change in head position exacerbates the pain.
  • Pain is worse in the morning or awakens the patient from sleep.
  • Projectile vomiting without nausea and focal seizures may occur. However, morning headaches and projectile vomiting once thought to be hallmarks of raised intracranial pressure may also occur from etiologies other than intracranial masses.
• Benign intracranial hypertension (pseudotumor cerebri)

  • Benign intracranial hypertension produces headaches similar to headaches in conditions with raised intracranial pressure.
  • In addition to having pain worse in the morning and vomiting, patients may have vision problems (eg, diplopia) or gait abnormalities (eg, ataxia).
• Epilepsy: Children with a prior history of epilepsy may have a generalized or focal headache after a seizure. Headaches may also accompany the aura prior to a seizure.
• Meningeal irritation: Meningeal irritation due to inflammation, infection, or hemorrhage (eg, malignant hypertension [HTN], vascular lesions) results in the acute onset of diffuse severe headache. Neck pain or stiffness and alteration in consciousness may be present.
• Medication overuse headache (MOH): Chronic use of all medications used to treat headaches, such as analgesics or vasoconstrictors, can result in medication overuse headache. The International Classification of Headache Disorders (ICHD) has recently recognized this entity. It is defined as the development of a different type of headache or worsening of a migraine or tension headache, resulting in chronic daily headaches. It develops after use of medications such as analgesics or the triptans on more than 10 days per month or after use of over-the-counter (OTC) analgesics for more than 15 days per month for 3 months' duration.

A thorough physical examination often can exclude systemic causes of headache.

• Attention should be paid to vital signs, especially presence of fever, elevated blood pressure, or bradycardia.
• A thorough neurologic examination should be performed to assess the level of consciousness and to evaluate cranial nerve dysfunction, hypertonia, hyperreflexia, hemiparesis, or hemiplegia.
• Perform funduscopic examination, looking for papilledema or subhyaloid hemorrhage.
• Look for nuchal rigidity.
• Check the head for hematomas or other signs of trauma.
• Search the skin for rashes or cutaneous lesions (eg, petechiae, purpura, Ash leaf spots, cafe-au-lait spots).
• Migraine headache

  • Most children with migraine headaches have a normal physical examination without focal deficits.
  • Some children with a complicated migraine may have focal neurologic abnormalities, such as weakness, third nerve palsy, or ataxia.
• Tension headache: Physical examination findings are usually normal. Pain on palpation of the posterior neck muscles may be noted.
• Sinus headache: Physical findings include pale edematous nasal mucosa, boggy turbinates, clear or yellow nasal discharge, pain with palpation of frontal or maxillary sinuses, and failure of these sinuses to transilluminate.
• Head trauma

  • In acute injuries, the child may have an altered level of consciousness, focal neurologic deficits, abnormalities in cranial nerve function (III, VI), and hemiparesis.
  • In chronic injuries, the physical examination findings often are normal.
• Intracranial masses

  • Patients with headaches due to intracranial masses often have focal neurologic abnormalities, especially if they have had headaches for several months.
  • These abnormalities include papilledema, sixth nerve palsy, ataxia, spasticity of the lower extremities, and indications of brain dysfunction regarding language, motor control, or vision (depending upon the location of the lesion).
  • Early in the course of the mass lesion, the physical examination findings may be normal.
  • Children with intracranial abscesses may have alteration of the level of consciousness only during the acute presentation.
• Benign intracranial hypertension (pseudotumor cerebri): These patients usually have papilledema and, occasionally, have other neurologic deficits (eg, sixth nerve palsy, ataxia, spasticity of the extremities).
• Epilepsy

  • Children with uncomplicated idiopathic epilepsy have normal physical examination findings.
  • Children with seizures due to metabolic or abnormal brain architecture may have baseline neurologic deficits (eg, hypertonia, hemiparesis).
• Meningeal irritation

  • Fever (meningitis), hypertension (malignant hypertension)
  • Altered consciousness, nuchal rigidity, or perivenous hemorrhage of the fundus (subarachnoid hemorrhage secondary to hypertension)

• Migraine headache

  • Minor headache
  • Onset of menses
  • Sleep disturbances
  • Chemicals (eg, tyramine in cheese, chocolate, nuts, monosodium glutamate [often in Chinese food])
  • Children with epilepsy are at an increased risk of developing migraine headaches.
• Tension headache

  • A subgroup of patients with tension headaches has obvious symptoms of depression, such as depressed mood, feelings of worthlessness, anhedonia, or anorexia.
  • In this subgroup of patients, the headaches are relieved when the depression is treated.
• Benign intracranial hypertension (pseudotumor cerebri)

  • Expansion of 1 or more of the intracranial fluid spaces, such as the vasculature, the extracellular fluid compartment, or the cerebrospinal fluid (CSF) space
  • Several drugs, such as tetracycline, minocycline, penicillin, gentamicin, oral contraceptives, steroids, indomethacin, thyroid hormone, and lithium carbonate may be inciting agents.
• Meningeal irritation

  • Infection (meningitis)
  • Inflammation (eg, tumor)
  • Hemorrhage (eg, vascular malformation, malignant hypertension)