Abstract
Headaches present frequently to the pediatric urgent care setting. This chapter discusses primary and secondary headaches in the pediatric patient, when to obtain emergent imaging for a headache, and subsequent management.
Keywords
cluster headache, increased intracranial pressure, meningitis, migraine headache, tension headache
1
An 8-year-old boy presents to your urgent care center with a 3-day history of frontal headache, associated with fever, sore throat, nausea, and vomiting. What is the basic differential for a nontraumatic pediatric headache?
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Primary headache: migraine, tension, cluster (in order of prevalence).
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Secondary headache: infections (such as meningitis, upper respiratory infection [URI], pharyngitis, sinusitis, otitis media, mastoiditis), medications, idiopathic intracranial hypertension, systemic hypertension, brain tumor, nontraumatic intracranial bleed (e.g., atrioventricular [A-V] malformation), and posttraumatic headache (covered separately).
3
What is the appropriate physical exam for a headache?
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Neurologic exam is essential. Six critical findings with headache: papilledema, ataxia, hemiparesis, abnormal eye movements, depressed reflexes, altered mental status.
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Exam to support secondary headache:
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Vital signs: fever, tachycardia or bradycardia, hypertension, orthostatic changes.
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General: findings to suggest dehydration (tacky or dry mucous membranes, decreased or absent tears, delayed capillary refill, reduced perfusion, decreased skin turgor).
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Head, ears, eyes, nose, and throat (HEENT): findings supporting URI, otitis media, sinusitis, streptococcal pharyngitis, dental etiology; mydriasis or nystagmus to support toxicologic etiology; papilledema or anisocoria, or cranial nerve palsy suggesting increased intracranial pressure; scalp hematoma to suggest trauma.
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Neck: meningismus, thyromegaly, carotid bruit, torticollis.
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Skin: neurocutaneous disorders (e.g., café-au-lait spots), Lyme disease (erythema migrans), petechiae or purpura (invasive bacterial infection).
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4
A 15-year-old girl presents to your urgent care center with right-sided, pulsating headache intermittently for 3 days that worsens with bright lights and loud sounds. What constitutes a migraine headache without aura?
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Lasts 2–72 hours.
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Usually frontal, pulsating, moderate to severe in pain intensity, aggravated by routine physical activity.
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Usually bilateral in childhood, may transition to unilateral in adolescents/adults.
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Nausea/vomiting, photo- or phonophobia.
6
What is a tension headache?
A headache that is mild to moderate in intensity and usually bilateral. It may be associated with photo- or phonophobia but not usually vomiting.