Headaches are common in childhood. As many as 90% of children experience a headache by the age of 18 years.^1,2 Although they usually do not result from serious disease, headaches are sometimes the manifestation of life-threatening illness. It is incumbent on the emergency physician to distinguish those headaches that result from benign, self-limited processes from those that can result in serious morbidity or mortality.

Headaches can be classified as primary or secondary. Primary headaches include migraine, tension-type, and cluster headaches, and are based on criteria defined by the International Headache Society (IHS) and the International Classification of Headache Disorders.³ Secondary headaches have identifiable etiologies based on history and physical examination. These include headaches attributed to head or neck trauma, infection (influenza, viral illness, meningitis, brain abscess, encephalitis), a vascular disorder such as bleed or stroke, a nonvascular intracranial disorder such as elevated intracranial pressure or a neoplasm, or a medication or toxin such as carbon monoxide, cocaine, or medication overuse.^1–5 Facial pain and sinus, eye, and dental problems can also cause headaches. Some patients with psychiatric disorders will complain of headache. The brain itself is not sensitive to pain, but there are pain-sensitive structures in the skin, the muscles, the vascular sinuses, the intracranial blood vessels, and the meninges at the base of the brain. Inflammation, dilation, irritation, and displacement of the pain-sensitive areas can result in a headache.⁴

The evaluation of a child for a headache includes information on the headache history. Based on this information, the headache can be classified as acute (sudden, first), acute and recurrent (episodic), chronic and progressive (steadily worsening), or chronic and nonprogressive.^1,2,4 One way to help determine headache etiology is demonstrated in Table 56-1.

The following information should be obtained: age at onset, frequency and duration (minutes, days), time of onset (day, night, school days only), location (frontal, temporal, occipital), quality of pain (stabbing, pressure, pounding), change in frequency of headache, associated symptoms (nausea/vomiting, photophobia), warning signs or aura (blurred vision, vertigo, nausea, weakness), precipitating factors (stress, coughing, certain foods), relieving factors (sleep), recent trauma, change in school or home environment, response to treatment at home, and family history of migraines.^1,2,4,5

The physical evaluation includes general appearance, blood pressure and temperature, height, weight, and head circumference. The eyes are assessed for extraocular nerve palsies or nystagmus. A funduscopic examination evaluates the possibility of papilledema. Examination of the head assesses the temporomandibular joints and sinuses. The neck is auscultated for bruits that would indicate an arteriovenous malformation, and assessed for the presence of meningismus or rigidity. The skin is examined for café-au-lait spots, neurofibromas, and ash-leaf spots. The neurologic examination includes strength testing, deep tendon reflexes, Romberg test, gait testing, cerebellar tests, Brudzinski’s sign, and Kernig’s sign.^1,2,5

The main concern for a physician is whether intracranial pathology exists. Risk factors/red flags for this include sleep-related headache, absence of family history of migraine, vomiting, absence of visual symptoms, worsening headache (more severe, more frequent), change in headache type, headache less than 6 months, confusion, exclusively occipital headaches, and an abnormal neurologic examination.^2,6 Findings associated with brain tumor headaches in children include papilledema, abnormal eye movements, ataxia, behavior change, altered mental status, and weakness.^2,6,7 Other life-threatening causes of headache that should not be missed include bacterial meningitis, orbital or cerebral abscess, viral encephalitis, hydrocephalus, intracranial hemorrhage, hypertensive encephalopathy, and carbon monoxide poisoning.

Laboratory studies should be performed based upon the suspected etiology of the headache. If the blood pressure is elevated, electrolytes, BUN, creatinine, and urinalysis are appropriate. For a child with a fever, CBC, blood cultures, and cerebrospinal fluid (CSF) studies if a lumbar puncture is performed are appropriate.^1,6,8

Neuroimaging should be performed for a child with signs of increased intracranial pressure, focal symptoms, an abnormal neurologic examination, seizures, skin lesions suggestive of a neurocutaneous syndrome, recent head trauma, severe headache in a child with an underlying disease that predisposes to intracranial pathology (e.g., sickle cell disease, coagulopathy, history of neoplasm) and a progressive neurologic disorder (Fig. 56-1).^1,5,8 While a computed tomography (CT) scan is usually adequate to see a space-occupying lesion, bleed, hydrocephalus, and abscess, magnetic resonance imaging (MRI) may be needed to demonstrate sellar lesions, some small posterior fossa lesions, white-matter abnormalities, and congenital anomalies. However, MRI may not be immediately available and may require that a young child be sedated for the procedure.^1,5,6

The American Academy of Neurology and the Child Neurology Society developed a practice parameter for the evaluation of children and adolescents with recurrent headaches. They stated that routine neuroimaging is not recommended in children with recurrent headaches and a normal neurologic examination. Neuroimaging should be considered in the child with headache who has an abnormal neurologic examination consisting of focal findings, signs of increased intracranial pressure, altered level of consciousness, or coexistent seizures or both. Neuroimaging should be considered in children with historical features to suggest recent onset of severe headache, change in the type of headache, or features that suggest neurologic dysfunction.⁸

A child suspected of having meningitis/encephalitis requires a lumbar puncture (LP). If there is concern for a subarachnoid hemorrhage, an LP can be diagnostic if the CT was inconclusive. In addition, if idiopathic intracranial hypertension (pseudotumor cerebri) is being considered, an LP with an opening pressure is required (>20 cm H₂O, with normal CSF findings is diagnostic).

The characteristics of primary headaches are described in Table 56-2.