Obtain a thorough history from all possible sources (child, parents, and other caretakers available) in order to help identify or exclude more worrisome secondary causes of headache (Table 136-1). Enquire about the child's personal and family medical histories. Elicit characteristic features of the headache. Obtain details as to whether the child or family has a history of headaches and whether the current headache is similar to past attacks.
AGE OF FIRST OCCURRENCE OR PATTERN OF PREVIOUS OCCURRENCES
The prevalence of migraine headaches increases with the child's age, and a pattern of prior occurrences suggests primary headache.3,4,11 Although migraine headaches are unusual in preschool-age or younger children (<5 years old), they are becoming increasingly recognized in this young age group.12 Complex migraines (hemiplegic, confusional, or basilar type) may have their onset at a young age as well; however, incapacitating headache in a young child, especially when associated with vomiting or gait changes, suggests an intracranial mass with an infratentorial location being the most common location.13 Predictors of a surgical space-occupying lesion include headache of <6 months' duration, sleep-related headache, vomiting, confusion, absence of visual symptoms, absence of family history of migraine, and abnormal findings on neurologic examination.14
Viral illnesses and fever are among the most common causes of headache in children, and the associated headaches are most frequently frontal or temporal.2,6,8 A history of trauma may suggest posttraumatic headache or traumatic brain injury. Posttraumatic headaches may be chronic as well.15 Migraines, more common and better studied in adults and adolescents, may be accompanied by premonitory symptoms (prodromes such as fatigue, mood changes, or GI symptoms) and have identifiable triggers.16 Children with prodromes tend to have more characteristic triggers as a whole, which may include specific foods (e.g., chocolate or monosodium glutamate), stress, light, specific odors, and weather changes.8,12 Headaches are among the most commonly reported symptoms in toxic exposures such as carbon monoxide poisoning.17 Additional precipitants include medications (e.g., methylphenidate, steroids, oral contraceptives, and anticonvulsants), infection (e.g., sinusitis, pharyngitis, or meningitis), hypertension, anemia, and substance abuse (e.g., cocaine).18
Headache coinciding with the onset of fever suggests inflammation of some sort, typically infectious (e.g., sinusitis, pharyngitis, otitis, or meningitis), or may be associated with a more general viral syndrome. Abrupt occurrence of severe headache due to a serious underlying condition, such as a brain tumor or intracranial hemorrhage, is typically associated with one or more objective findings on neurologic examination (e.g., altered mental status, ataxia, nuchal rigidity, papilledema, or hemiparesis).7,8 Cluster headaches also tend to develop acutely, whereas tension headaches have a more subacute onset. Hormonal cycles can trigger migraine headaches in adolescent females. Migraine headaches in children typically start relatively abruptly, intensify over several minutes, and then reach full intensity in about an hour.19 Young children often have headaches that begin in the late afternoon.
In a cohort of children with headaches presenting to a pediatric ED, only 27.5% of patients could identify a precise location of the pain. Among children with intracranial diseases, most either were unable to indicate the location of the pain or had an occipital headache.7,20 Medications, hypertension, and basilar-type migraines can also cause headaches in the occipital region. Pain at the vertex can be seen with sphenoid sinusitis. Ethmoid, maxillary, and frontal sinus infections tend to cause retro-orbital pain, as does meningitis (along with fever and neck stiffness) and dural sinus thrombosis. Pain seemingly in, around, or in front of the ear (or entire temporal region) is often seen with temporomandibular joint dysfunction and can be reproducible on exam. Migraine headaches are usually unilateral and involve the frontal or temporal region in adolescents. However, in younger children, they are usually bifrontal or generalized. Only about a third of children have unilateral migraines.19 Tension headaches tend to have the greatest variability in location. They may be generalized, frontal, or even occipital/posterior cervical. Occipital location in children is a red flag that should be investigated further before attributing to a primary headache disorder.
Younger children and many developmentally normal, otherwise healthy children may have a difficult time describing the quality of their headaches. An ability to describe pain quality or a description of the headache as having a pulsating quality is more frequently associated with benign headaches. An inability to describe the pain or a description of the headache as constrictive indicates a greater likelihood of a more serious cause.7,8,20 Many different qualities of pain can be identified: stabbing or hyperesthetic pain has been associated with herpes zoster; aching pain with tension headaches, meningitis, or encephalitis; and constant pain with sinusitis in all locations. A pulsating quality is one of the diagnostic criteria for migraine headache set forth by the International Headache Society but can also be seen with headaches caused by hypertension or intracerebral hemorrhage.21 The International Headache Society criteria for migraine were developed for the adult population, but children present differently. In particular children, may have shorter headaches and in different locations. Diagnostic criteria for pediatric migraine are presented in Tables 136-3 and 136-4.22 Although these diagnostic criteria rely on recurrent attacks, in an ED, a child may present with a first migraine headache due to intractable pain. One study investigated the utility of applying the International Headache Society criteria in the ED without the "recurrent" requirement ("Irma Criteria") and found the criteria to be quite sensitive in diagnosing first-time migraines when followed long term using the original International Headache Society criteria as the gold standard.23
TABLE 136-3Diagnostic Criteria for Pediatric Migraine Headache without Aura ||Download (.pdf) TABLE 136-3 Diagnostic Criteria for Pediatric Migraine Headache without Aura
|I ||At least 5 attacks with features (II–IV) below |
|II ||Headache between 1 and 48 h |
|III || |
At least 2 of the following:
Bilateral or unilateral location (not to include posterior location)
Made worse with activity
|IV || |
At least one associated symptom:
TABLE 136-4Diagnostic Criteria for Pediatric Migraine Headache with Aura ||Download (.pdf) TABLE 136-4 Diagnostic Criteria for Pediatric Migraine Headache with Aura
|I ||At least 2 attacks with features below |
|II || |
At least 3 of the following:
Gradual development of autonomic aura
Aura that is fully reversible
Aura is present less than 1 h
Headache within 1 h of aura
The severity of a headache is neither a sensitive nor a specific characteristic in determining cause. Patients with tension headaches can complain of terrible pain, whereas a child with a brain tumor may complain of mild to moderate pain. Nonetheless, complaints of very intense pain should be taken seriously and assessed in context with other historical elements.7 Ask about and document presenting pain assessments in children with primary headache disorders because treatment end points will be dictated by improved pain scores in the ED.
Although the duration of a headache is not particularly useful in assessing the majority of headaches, the International Headache Society definition of migraines requires a duration of symptoms of 4 to 72 hours21 in adults, but the duration may be less (1 to 48 hours)22 in children (Tables 136-3 and 136-4). A migraine that lasts >72 hours is known as status migrainosus. Children can sometimes come to the ED with this condition and should be treated appropriately.
ALLEVIATING AND EXACERBATING FACTORS
Patients with a sense of restlessness or agitation are more likely to have cluster headaches (more rare in children; Table 136-5).21 They may pace about the room or rock back and forth in a chair. In contrast, patients with migraines typically prefer silence and darkness because the lack of stimulation provides some relief, and photophobia/phonophobia are part of the diagnostic criteria for migraine headache (Table 136-3).21,22 Tension headaches can be frequent and frustrating but tend not to be aggravated by routine physical activity (Table 136-6).21 Positional preferences (such as a head tilt) may be noted in children with space-occupying lesions, in order to avoid positions that increase intracranial pressure or exacerbate diplopia caused by cranial nerve dysfunction. In addition, children with increased intracranial pressure may be unable to look up or may avoid the Valsalva maneuver (e.g., defecation or coughing). Analgesic rebound headaches worsen when the patient goes a certain period of time without taking long-term pain medication or overuses analgesics.
TABLE 136-5International Headache Society Diagnostic Criteria for Cluster Headache24 ||Download (.pdf) TABLE 136-5 International Headache Society Diagnostic Criteria for Cluster Headache24
At least five attacks of headache fulfilling the following criteria:
1. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15–180 min if untreated
2. Headache is accompanied by at least one of the following:
Ipsilateral conjunctival injection and/or lacrimation
Ipsilateral nasal congestion and/or rhinorrhea
Ipsilateral eyelid edema
Ipsilateral forehead and facial sweating
Ipsilateral miosis and/or ptosis
A sense of restlessness or agitation
3. Attacks have a frequency from one every other day to eight per day
4. Not attributed to another disorder
TABLE 136-6International Headache Society Diagnostic Criteria for Tension Headache24 ||Download (.pdf) TABLE 136-6 International Headache Society Diagnostic Criteria for Tension Headache24
Infrequent episodic—at least 10 episodes occurring on <1 d per month on average (<12 d per year) fulfilling criteria 1–4
Frequent episodic—at least 10 episodes occurring on ≥1 but <15 d per month for at least 3 mo (≥12 and <180 d per year) fulfilling criteria 1–4
1. Headache lasting from 30 min to 7 d
2. Headache has at least two of the following characteristics:
Pressure or tightening (nonpulsating quality)
Mild or moderate intensity
Not aggravated by routine physical activity such as walking or climbing stairs
3. Both of the following:
No nausea or vomiting (anorexia may occur)
No more than one of photophobia or phonophobia
4. Not attributed to another disorder
Eliciting associated symptoms can help narrow the differential diagnosis. Migraine headache with aura, by definition, is associated with visual, sensory, or speech disturbances (all fully reversible; Table 136-4).22 Specific symptomatology may distinguish between types of migraines such as confusional (e.g., distortions of visual size, space, or time) and hemiplegic (e.g., transient hemiparesis or aphasia). Hemiplegic migraines are uncommon, so think carefully about other causes of neurologic deficits when contemplating the differential diagnosis. Abdominal pain, nausea, or vomiting may occur along with migraine headache.10 Cluster headaches can be associated with multiple ipsilateral symptoms (Table 136-5).21 Headache with effortless vomiting but no GI complaints is characteristic of elevated intracranial pressure.7 Irreversible and progressive defects in visual acuity and diplopia are more suggestive of pseudotumor cerebri. Seizures and headache may indicate traumatic brain injury, concussion, arteriovenous malformation, subarachnoid hemorrhage, or tumor. A headache with fever and focal neurologic signs (with or without seizure) may suggest an intracranial abscess, encephalitis, or meningitis (especially with neck stiffness). Children who present with headache, altered mental status, and seizures must be evaluated for meningoencephalitis from herpes simplex virus.25
Headaches should be considered both independently and within the context of the child's medical history because secondary headaches can occur even when there is a history of primary headaches. It is helpful if a child has a history of similar headaches, but a first-time headache does not preclude a primary headache disorder as described previously.23 Concurrent chronic illness may predispose the patient to unique headaches (e.g., those associated with ventriculoperitoneal shunt malfunction or infection), headaches from infection (e.g., related to anatomic defects predisposing to meningitis or acute illness with sinusitis leading to brain abscess), or headaches caused by intracranial hemorrhage (e.g., due to hemophilia or anatomic arteriovenous anomalies). Although the ED is a location for acute care, taking a history regarding psychological factors can be important, because children have been shown to have psychosomatic headaches as well.26
Headaches occur more often in children who have a family history of headaches in either first- or second-degree relatives.27 This association is particularly true for children with migraines (family history of migraines in up to 90% of cases). Children with cluster headaches rarely have a family history of similar headaches (about 7%). Children with a parent who experienced a subarachnoid hemorrhage are at a four times greater risk of this type of intracranial bleed than the general population. Predisposing genetic disorders may provide some clue to a familial link in headaches (e.g., bleeding diathesis, familial dyslipidemias, or atherosclerotic events).