Pediatric Headache Workup

Updated: Jan 02, 2019
  • Author: J Ivan Lopez, MD, FAAN, FAHS; Chief Editor: George I Jallo, MD  more...
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Approach Considerations

In the case of migraine or tension headache, a thorough history and physical examination is usually all that is needed. Laboratory, radiologic, or encephalographic studies are not useful to confirm the diagnosis of migraine but may help to exclude other causes of headache. For example, electroencephalography may be helpful to exclude seizures in children with acute confusional migraines.

Although imaging studies are not needed for every child who complains of headache, neuroimaging should be performed when the caregiver has any suspicion or concern that the headache may have a structural etiology. Given the broad differential of structural headaches and the imaging choices that are available, many practitioners are unsure which imaging modality will yield the most information in a cost-effective manner.

If a patient has had headaches for a long time (months to years) and the neurologic examination is normal, the likelihood of this patient harboring any serious intracranial pathology is minimal, and, therefore, neuroimaging studies should not be performed routinely.

Electroencephalography is useful to assess the status of an underlying seizure disorder associated with headache.


Laboratory Studies

In cases of headache associated with head trauma or a significant intracranial hemorrhage, a consumptive coagulopathy, such as thrombocytopenia, and prolonged prothrombin and activated partial thromboplastin times may be evident. Thus, a complete blood count (CBC), prothrombin time (PT), and activated partial thromboplastin time (aPTT) may be indicated in such cases.

Check anticonvulsant levels in patients with a headache and a known history of epilepsy because adequate seizure control usually prevents the headache.


Lumbar Puncture

A lumbar puncture may reveal elevated opening pressure, leukocytosis, elevated protein level, and low glucose level. For example, in patients with meningitis, a lumbar puncture may show an elevated opening pressure, white blood cells (WBCs), low glucose level, high protein level, and bacteria on Gram stain.

Lumbar puncture is the most sensitive test in the diagnosis of subarachnoid hemorrhage, demonstrating hemorrhagic cerebrospinal fluid (CSF) that does not clear during the collection of the first and last tubes. Opening pressure may also be elevated.


Imaging Studies

Neuroimaging (eg, computed tomography [CT] scanning, MRI) usually is not indicated for the routine care of patients with headache except possibly in the very young child and if absolutely no family history can be found despite thorough review. However, according to a study of over 700 children by Graf et al, there appears to be an increase in the rate at which neuroimaging for nonacute headache is being ordered by primary care physicians. [42]

If the baseline neurologic examination changes, neuroimaging should be considered. Neuroimaging is also warranted, despite normal baseline examination findings, if a patient’s first seizure is coincident with a headache, to exclude the possibility of an intracranial mass.


Diagnosis of sinus headache may be made by sinus radiographs depicting air-fluid levels in the sinuses. However, this test is not sensitive, and false-negative results are common. CT scanning of the sinuses is more sensitive but is usually more expensive.

CT scanning

Any abnormality on physical examination in children with head trauma and headache should prompt radiologic evaluation, such as CT scanning, provided that the child has a protected airway and stable cardiovascular status.

Structural lesions

A CT brain scan with contrast can define most structural lesions. A CT scan without contrast is somewhat more limited in its sensitivity, although it can define hydrocephalus and hemorrhage easily. Routine noncontrast CT should be reserved for more acute situations in which time is crucial and intracranial hemorrhage is suspected.

Intracranial hemorrhage

CT scanning is the best initial study to demonstrate intracranial hemorrhage from malignant hypertension or vascular lesions. However, CT scan findings are positive in only about 90% of patients with subarachnoid hemorrhage, so a lumbar puncture should be performed despite unremarkable CT scan findings in patients thought to have a subarachnoid hemorrhage.

Intracranial hypertension

CT scan findings may be normal or may show slit-like ventricles in patients with benign intracranial hypertension (pseudotumor cerebri). CT scanning is usually needed to exclude other causes of increased intracranial pressure, such as tumors. Intracranial masses are most often diagnosed by means of CT scanning (with contrast to enhance subtle lesions) or MRI.

Sinus headache

In children with sinus headache, CT scanning of the sinuses is sensitive but expensive. Note that there is often mucoperiosteal thickening in the paranasal sinuses of children, so that it is difficult to determine whether the soft tissue changes of the sinuses are due to either bacterial infection or inflammation from other causes, such as viral infection, allergy, or chemical irritation. Thus, CT scanning should not be used to make the diagnosis of sinusitis but, rather, should be obtained only in children in whom antibiotic therapy has not ameliorated symptoms or in whom sinus surgery is being considered after appropriate antibiotic therapy has failed.


MRI is generally more costly, takes longer, and may require sedation, but its superior imaging capabilities offer detailed structural definition overall. Visualization of the posterior fossa in particular is superior to that achieved with CT scanning. Gadolinium enhances MRI sensitivity of vascular lesions and those that disrupt the blood-brain barrier.

All patients who present with any features of a structural headache should undergo high-quality imaging, preferably an MRI scan with gadolinium enhancement. In less suggestive clinical situations or for parental or patient reassurance, routine MRI or high-quality CT scanning with contrast is sufficient.