Headache

Taking a moment to observe the patient initially can often prevent anxiety or apprehension on the patient's end when performing the full exam later. In addition, the physician can learn a lot by simply observing.

• Is the patient awake, alert, and talking?
• Are they moving their head and neck around freely?

This information is helpful in the initial evaluation of the patient. The primary survey of any patient involves assessing airway, breathing, and circulation. If the patient is talking and moving their head and neck without difficulty, the patient’s airway is stable. Next, it’s important to assess breath sounds through lung auscultation and assess circulation by palpating pulses and measuring capillary refill. While performing the primary survey, it is important to take note of the patient’s vital signs as well. If on your initial assessment you notice that a child is obtunded, has mottled skin, and/or has hypotension, you will need to address this right away. If concerned about meningitis, you may start with prompt initiation of IV antibiotics, IV fluids, and a sepsis protocol. In contrast, when a child is running around the room or playing, your initial response may be to perform a history and physical exam.

Early in your assessment, you should ask the patient if they are experiencing light sensitivity and would prefer the lights to be dimmed. This may help the patient feel more comfortable. Also, closing the door can help minimize outside noises, which may be helpful to patients experiencing phonophobia.

Vital signs are often documented in triage prior to evaluation by a physician. Look at the vitals and take note of any abnormalities. Is the patient febrile? Are they hpo- or hypertensive? Are they tachycardic? You may start to formulate a differential diagnosis based on vitals alone. For example, the combination of hypertension and bradycardia may suggest Cushing's reflex, which is the body's physiological response to increased intracranial pressure. Cushing's reflex is characterized by hypertension, bradycardia, and irregular breathing.

It is important to also read the triage note. What other signs and symptoms are noted by the nurse? With regards to triage notes, it’s important to be cautious of introducing bias into your decision-making. Reading another person’s account of the patient’s presentation can lend itself to anchoring bias. If the note suggests the patient is in distress or has high acuity, immediately proceed to the patient’s room.

Now it’s time to evaluate your patient. Referring to what we learned earlier, first observe your patient. What do we see? Is the patient awake and alert? Are they sitting peacefully on the stretcher? Are they moving their head and neck freely? Are they walking or running around the room without gait abnormality? All these signs suggest the patient is not in acute distress. Conversely, if the patient appears to have a stiff neck and is febrile, this may suggest meningitis. If they have a gait abnormality or difficulty with coordination, it could be secondary to an intracranial space-occupying lesion or cerebellar disorder. For example, cerebellitis can occur with viral illnesses and present with fever, emesis, and gait abnormality. If the patient is sitting in a dark room with sunglasses, this suggests photophobia and could be secondary to a migraine. 

When obtaining a history, it’s best to start with an open-ended question. For example, what brings you in today? How are you feeling? Histories in pediatric patients are often provided by both patients and their parents. 

If the patient has had recurrent emesis over a prolonged course, this could be reflective of an intracranial mass. This is especially true when the episodes of emesis occur in the morning as there tends to be a build-up of intracranial pressure while laying down. Other signs of an intracranial mass include visual changes such as diplopia, focal neurologic deficits, or seizures. In the event of a first-time seizure (in the absence of febrile seizure criteria), obtain CT head imaging. If the patient describes the headache as acute in onset and severe, this could be secondary to a subarachnoid hemorrhage. While most subarachnoid hemorrhages occur in adults, it can present in children as well.^3-4 If the patient has a history of headaches and their current episode is similar to prior ones in terms of location, quality, and severity, then it is likely related to their history of headaches. 

Environmental exposures also pose a risk to patients, so it is important to ask about recent travel, camping, and even their home environment. For example, approximately 20% of children in the United States live in a rural setting. This means potential exposures to parasites and other pathogens from farm animals and flora. 

There are also less severe and more common etiologies of headache. Some are infectious such as viral upper respiratory tract infection, Group A Streptococcal pharyngitis, and sinusitis. Others include migraine, tension headache, and cluster headache. Concussions are another cause of headache, however it is important to note that this module will not cover traumatic brain injuries as those are covered separately in this series. 

It's important to consider past medical history and how that may be contributing to the patient’s headache. If the patient has a history of a blood clotting disorder such as factor V Leiden mutation or sickle cell anemia, they are at higher risk for developing a blood clot. In these patients, consider a cerebral venous thrombosis and order a MRV. Conversely, if their clotting disorder predisposes them to bleeding, as seen in hemophilia, then consider intracranial hemorrhage. 

If the patient is immunocompromised (for example, history of cancer, sickle cell disease, asplenia, autoimmune disorder, acquired immune disorder), they are more susceptible to infection. As such, CNS infections such as meningitis and brain abscesses should be considered. It’s worth noting here that if your patient has a history of cancer, their headache may represent metastatic spread and in which case CT head imaging is indicated. Does your patient have a history of a ventriculo-peritoneal (VP) shunt? Then obtain a shunt series and CT head to evaluate for an occluded or malfunctioning shunt as a shunt obstruction can present with headache, vomiting, altered mental status, cranial nerve palsies and ataxia. 

It is also important to note if the patient has cyanotic heart disease. Patients with a persistent right to left shunt are at higher risk for brain abscess than the general pediatric population. This is because any venous bacteremia might not be filtered out by the pulmonary circulation. Clinicians should have a low threshold for ordering a head CT when a patient with cyanotic heart disease presents with a headache.

The physician should also ask about events surrounding the onset of the symptoms. Are there other family members with similar symptoms? If so, consider carbon monoxide poisoning, especially if there is recent onset of cooler weather and use of heaters.

Lastly, the physical exam will provide you with additional clues to further differentiate your list of potential diagnoses. If your patient has any focal neurological deficits such as limb weakness or numbness or a facial droop, consider an intracranial mass or hemorrhage. The fundoscopic exam can also provide useful information if you see papilledema as that suggests increased intracranial pressure. While on the topic of eye exams, if you see anisocoria, this could be a benign, incidental finding, or reflective of brainstem herniation. In the case of brainstem herniation, the patient will likely have additional findings of neurologic compromise prior to the eye exam. They may be obtunded, unresponsive, seizing, hypertensive, bradycardic, and have impaired breathing among other things. Otherwise, anisocoria is a benign finding in many patients and does not require additional work-up. 

If your patient is altered or obtunded, then broaden the differential to include infectious, cardiac, hematologic, endocrine, and environmental pathologies and assess if their airway is stable. If family members have similar symptoms, this may be secondary to carbon monoxide poisoning. 

It is important to note that eye disorders can also cause a headache. In instances where a clear etiology is not found, consider asking if the patient is experiencing visual changes or had trauma to the eye. For example, a patient could have a corneal abrasion that is causing a headache. 

Do a complete neurologic exam for all patients. Assess mental status, cranial nerves, fundoscopic examination, motor and sensory function in the extremities, reflexes, cerebellar testing, and ambulation as appropriate for age. Any new focal neurologic deficit requires neuroimaging and is most commonly of very serious origin such as mass or hemorrhage.

The general approach in emergency medicine (EM) applies to pediatric headache as well - consider the high acuity, life-threatening possibilities and rule them out. Emergent causes of headache include:

• Intracranial hemorrhage.
• CNS infection.
• CNS mass or space-occupying lesion.
• VP shunt malfunction.
• Carbon monoxide poisoning.
• Hypertensive crisis.
• Cervical artery dissection.

Below is a list of common discharge diagnoses for the pediatric headache:

• Viral upper respiratory infection.
• Otitis media.
• Sinusitis.
• Dental infections.
• Pharyngitis.
• Migraine.
• Tension headache.
• Concussion.

If there is concern for an intracranial mass, space-occupying lesion, or hemorrhage, then obtain CT head imaging. This is also true for patients with a VP shunt as their headache may reflect shunt malfunction. In these cases, a shunt series should be obtained along with the CT head. 

When considering a cerebral venous thrombosis, CTV may not be enough. While this may be the initial imaging modality, MRV has higher sensitivity and specificity and therefore should be considered if the CTV is negative and clinical suspicion remains high. As discussed earlier, in cases where the patient is altered, obtunded, seizing, or toxic appearing, expand the differential and work-up to include EKG, troponin, CXR, CBC, CMP, and CT head. 

A lumbar puncture (LP) for cerebrospinal fluid (CSF) studies may be indicated as well, especially if the patient is febrile, has petechiae, and has neck pain. It is important to obtain a CT head before performing a LP to prevent uncal herniation in the event the patient has a space-occupying lesion. If the CSF studies show sterile pleocytosis, consider the possibility of a parasitic infection like Naegleria Fowleri. While less common, patients who recently camped and were exposed to contaminated water are at risk. 

Lastly, if family members or others in the household have similar symptoms, then consider an environmental exposure like carbon monoxide poisoning and obtain a carboxyhemoglobin test. This measures the amount of hemoglobin that is bound to carbon monoxide.

Treatment for your patient depends on your working differential and is at times empiric. If you have a sick, altered child with signs of uncal herniation, consider empiric treatment with hypertonic saline or mannitol. Similarly, if there is high suspicion for bacterial meningitis, do not wait for the CSF studies to result and instead initiate treatment with broad-spectrum antibiotics after promptly collecting a CSF sample via lumbar puncture. In cases where multiple family members have a headache and there is concern for carbon monoxide poisoning, apply 100% Oxygen by non-rebreather mask until the carboxyhemoglobin level falls <10%. If the lactic acid level is high, consider concomitant cyanide toxicity. 

Otherwise, if your patient is non-toxic appearing and stable, consider the most likely diagnosis and treat accordingly. If there is concern for a migraine or tension headache, treat with Toradol (if the patient is not pregnant) alone. Alternatively, you can treat with Compazine. A few studies have shown treatment with compazine alone is more efficacious than toradol.^5-6 If there is concern for a cluster headache, treat with oxygen via non-rebreather mask. 

As for other etiologies of headache such as VP shunt malfunction, consult neurosurgery for shunt intervention. If a CT head shows intracranial mass or hemorrhage, this will also require neurosurgical evaluation.

Treatment for secondary headaches is going to depend on what your suspicion is for the etiology of the headache. For example, analgesics such as acetaminophen or ibuprofen may be the treatment of choice for a patient with a headache from an upper respiratory tract infection. In contrast, if a patient has a fever, altered mental status, and findings concerning for meningitis, prompt initiation of antibiotics and a lumbar puncture may be indicated. Given there are a multitude of etiologies that cause secondary headaches, we will not go into the nuance of treating each of these.

• Although most children who present to the ED with headache do not have a life-threatening etiology, clinicians must maintain a high indication of suspicion when concerning risk factors and high-risk clinical features are present.
• In cases where there is high suspicion for a cerebral venous thrombosis, a CTV alone is not sufficient to exclude the diagnosis. An MRV is needed.
• If there is concern for bacterial meningitis, promptly perform the LP so that empiric antibiotics can be started.
• For patients who present with photophobia and phonophobia, ask your patient if you can dim the lights and help minimize noise in their room by turning off the TV or closing the door.

1. Perry MC, Yaeger SK, et al. A Modern Epidemic: Increasing Pediatric Emergency Department Visits and Admissions for Headache. Pediatr Neurol. 2018 Dec.
2. Conicella E, et al. The Child with Headache in a Pediatric Emergency Department. Headache. 2008 Jul.
3. Sorteberg A, Dahlberg D. Intracranial Non-Traumatic Aneurysms in Children and Adolescents. Curr Pediatr Rev. 2013 Nov.
4. Levy ML, et al. Pediatric Cerebral Aneurysm. StatPearls Publishing. 2024 Jan.
5. Seim MB, et al. Intravenous Ketorolac vs Intravenous Prochlorperazine for the Treatment of Migraine Headaches. Acad Emerg Med. 1998 Jun.
6. Brousseau DC, Duffy SJ, et al. Treatment of Pediatric Migraine Headaches: A Randomized, Double-Blind Trial of Prochlorperazine vs Ketorolac. Ann Emerg Med. 2004 Feb.
7. Kan L, et al. Headaches in a Pediatric Emergency Department: Etiology, Imaging, and Treatment. Headache: The Journal of Head and Face Pain. 2000.
8. Costa FM, Ferreira IP, et al. Diagnosis and Treatment of Headache in a Pediatric Emergency Department. Pediatric Emergency Care. 2020.
9. Sheridan D, Meckler GD. Headache in Children. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill Education. 2020.
10. Lanphear J, Sarnaik S. Presenting Symptoms of Pediatric Brain Tumors Diagnosed in the Emergency Department. Pediatric Emergency Care. 2014.