Headache




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

 





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?





  • Primary headache: migraine, tension, cluster (in order of prevalence).



  • 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).






How is the timing of a headache important?





  • A headache may be acute, acute-recurrent, chronic-progressive, or chronic-nonprogressive.



  • Chronic-progressive headaches are those that may be indicative of a gradual increase in intracranial pressure and warrant concern of space-occupying lesions.






What is the appropriate physical exam for a headache?





  • Neurologic exam is essential. Six critical findings with headache: papilledema, ataxia, hemiparesis, abnormal eye movements, depressed reflexes, altered mental status.



  • Exam to support secondary headache:




    • Vital signs: fever, tachycardia or bradycardia, hypertension, orthostatic changes.



    • General: findings to suggest dehydration (tacky or dry mucous membranes, decreased or absent tears, delayed capillary refill, reduced perfusion, decreased skin turgor).



    • 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.



    • Neck: meningismus, thyromegaly, carotid bruit, torticollis.



    • Skin: neurocutaneous disorders (e.g., café-au-lait spots), Lyme disease (erythema migrans), petechiae or purpura (invasive bacterial infection).







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?





  • Lasts 2–72 hours.



  • Usually frontal, pulsating, moderate to severe in pain intensity, aggravated by routine physical activity.



  • Usually bilateral in childhood, may transition to unilateral in adolescents/adults.



  • Nausea/vomiting, photo- or phonophobia.






What is a migraine with aura?


A fully reversible focal visual, sensory, speech, motor, brainstem, or retinal attack that lasts for 5–60 minutes and is accompanied by or followed by a headache within 60 minutes of onset.





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.

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Sep 15, 2018 | Posted by in EMERGENCY MEDICINE | Comments Off on Headache

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