Chapter 77. Headache and Altered Mental Status in Children

Up to 1% of emergency department visits are for complaints of headache. The vast majority of headaches in children have a benign etiology. Factors associated with serious or dangerous causes of headache include: preschool age, occipital location, recent onset of headache, and inability of the child to describe the quality of the head pain.

Clinical Features

Headaches can be classified as primary or secondary. Primary headaches are physiologic or functional (migraine, tension, cluster) and tend to be self-limited. They are often recurrent and patients have normal physical examination findings. Secondary headaches often have an anatomic basis (vascular malformation, tumor, or infection) and are associated with higher morbidity and mortality than primary headaches. A careful history and physical examination can usually differentiate between the two. History suggestive of a secondary headache includes acute onset; morning vomiting; behavioral changes; altered mental status; “worst ever” headache; wakes the child from sleep; headache associated with fever, trauma, or toxic exposure; or aggravated by coughing, Valsalva, or lying down. Physical findings suggestive of secondary headaches include blood pressure abnormalities, nuchal rigidity, head tilt, ptosis, retinal hemorrhage or optic nerve distortion, visual field defects, gait disturbances, or focal motor or sensory deficits

Diagnosis and Differential

There are no evidence-based studies guiding diagnostic workup in children. Obtain a history from all possible sources. The history should include characteristic features of the headache such as age of first occurrence, precipitants, time and mode of onset, location, quality and severity of pain, duration of headache, and associated symptoms. Physical examination should include a thorough general examination in addition to a careful neurologic examination with attention to cranial nerves, gait, strength, and mental status. The selection of studies will depend on findings obtained from the history and physical examination. Head computed tomography and magnetic resonance brain imaging may be indicated in trauma or workup of secondary headaches (eg, patients with ventriculoperitoneal shunts, occipital headaches that are poorly characterized). Practice guidelines do not recommend routine imaging for children with recurrent headaches and normal findings on neurologic examination.

Emergency Department Care and Disposition

1. For secondary headaches: treat underlying cause and pain.

2. For primary headaches, treat based on type of headache diagnosed through historical features. Most primary headaches can be treated with first line oral therapy, typically ibuprofen 10 milligrams/kilogram.

3. For migraines: other medications include prochlorperazine 0.15 milligram/kilogram IV (consider administration with diphenhydramine 1 milligram/ kilogram IV to prevent dystonic reactions), dihydroergotamine 0.1 milligram/kilogram (ages 6 to 9) 0.15 milligram/kilogram (ages 9 to 12) or 0.2 milligram/kilogram (ages 12 to 16) can be given but is contraindicated in patients with complex migraine.

4. Cluster and tension headaches are managed much the same way as migraines. Sumatriptan 10 milligrams (20 to 39 kilogram) or 20 milligrams (> 40 kilogram) nasal spray or 0.1 milligram/kilogram subcutaneously and high-flow oxygen (7 L/min non-rebreather mask) can be used for cluster headaches. ...