Pediatric Headache in Emergency Medicine Workup

  • Author: Kirsten A Bechtel, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Mar 26, 2010
 

Laboratory Studies

  • Migraine headache
    • A thorough history and physical examination usually is all that is needed.
    • Laboratory, radiologic, or encephalographic studies are not useful to confirm the diagnosis of migraine but may help exclude other etiologies of headache. For example, an EEG may be helpful to exclude seizures in children with acute confusional migraines.
  • Tension headache
    • A thorough history and physical examination is all that is needed to make the diagnosis of tension headache.
    • With a suggestive history and normal physical examination findings, no additional tests are required.
  • Head trauma and headache due to a significant intracranial hemorrhage: A consumptive coagulopathy, such as thrombocytopenia, and prolonged prothrombin and activated partial thromboplastin times, may be evident.
  • Intracranial abscess: Lumbar puncture may reveal elevated opening pressure, leukocytosis, elevated protein level, and low glucose level.
  • Benign intracranial hypertension: Lumbar puncture reveals elevated opening pressure without leukocytosis or abnormalities in glucose or protein concentration.
  • Meningeal irritation
    • In patients with meningitis, a lumbar puncture may show an elevated opening pressure, WBCs, low glucose level, high protein level (meningitis, encephalitis), and bacteria on Gram stain.
    • In patients with a subarachnoid hemorrhage, a lumbar puncture demonstrates hemorrhagic CSF that does not clear during the collection of the first and last tubes. Opening pressure may also be elevated.
    • Lumbar puncture is the most sensitive test in the diagnosis of subarachnoid hemorrhage.
  • Check anticonvulsant levels in patients with a headache and a known history of epilepsy because adequate seizure control usually prevents the headache.
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Imaging Studies

  • Sinus headache
    • The diagnosis of headache due to sinusitis is suggested by a history of persistent upper respiratory infection (URI) symptoms lasting longer than 10 days.
    • Confirmation of the diagnosis may be made by means of sinus radiographs depicting air fluid levels in the sinuses. However, this test is not sensitive, and false-negative results are common.
    • CT of the sinuses is more sensitive but is usually more expensive. Note that there is a high prevalence of mucoperiosteal thickening in the paranasal sinuses of children in general and serves to emphasize that when soft tissue changes of the sinuses are present, it does not necessarily indicate whether these changes are due to either bacterial infection or inflammation from other causes, such as viral infection, allergy, or chemical irritation. Thus, CT should not be used to make the diagnosis of sinusitis but should only be obtained in children in whom antibiotic therapy does not ameliorate symptoms or in whom sinus surgery is considered after failing appropriate antibiotic therapy for sinusitis.
  • Head trauma
    • Any abnormality on physical examination in children with head trauma and headache should prompt radiologic evaluation, such as CT, provided that the child has a protected airway and stable cardiovascular status.
    • An MRI may not reveal accompanying skull fractures.
  • Intracranial masses are most often diagnosed by means of CT (with contrast to enhance subtle lesions) or MRI.
  • Benign intracranial hypertension (pseudotumor cerebri)
    • CT findings may be normal or may show slit-like ventricles.
    • CT is usually needed to exclude other causes of increased intracranial pressure, such as tumors.
  • Meningeal irritation
    • CT findings are positive in only about 90% of patients with subarachnoid hemorrhage. For this reason, a lumbar puncture should be performed despite unremarkable CT findings in patients thought to have a subarachnoid hemorrhage.
    • CT is the best initial study to demonstrate intracranial hemorrhage from malignant HTN or vascular lesions.
  • Epilepsy
    • If the baseline neurologic examination changes, neuroimaging should be considered.
    • If this is the patient's first seizure and it is coincident with a headache, neuroimaging (eg, CT, MRI) is warranted, despite normal baseline examination findings, to exclude the possibility of an intracranial mass.
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Other Tests

  • Electroencephalography (EEG) is useful to assess the status of an underlying seizure disorder associated with headache.
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Contributor Information and Disclosures
Author

Kirsten A Bechtel, MD  Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

William G Gossman, MD  Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center

William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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