Acute: Single episode of pain without a history of such episodes. The “first and worst” headache, which raises concerns for aneurysmal subarachnoid hemorrhage in adults, is commonly due to febrile illness related to upper respiratory tract infection in children. Regardless, more ominous causes of acute headache (hemorrhage, meningitis, tumor) must be considered.
Acute recurrent: Pattern of attacks of pain separated by symptom-free intervals. Primary headache syndromes, such as migraine or tension-type headache, usually cause this pattern. Infrequently recurrent headaches can sometimes also be attributed to certain epilepsy syndromes (benign occipital epilepsy), substance abuse, or recurrent trauma.
Chronic progressive: Most ominous of the temporal patterns— implies a gradually increasing frequency and severity of headache. The pathologic correlate is increasing ICP. Causes of this pattern include pseudotumor cerebri, brain tumor, hydrocephalus, chronic meningitis, brain abscess, and subdural collections.
Chronic nonprogressive or chronic daily: Pattern of frequent or constant headache. Chronic daily headache generally is defined as >4-month history of >15 headaches/month, with headaches lasting >4 hours. Affected patients have normal neurologic examinations; psychological factors and anxiety about possible underlying organic causes are common.
numbness, unilateral weakness, or vertigo that persist for hours, then resolve completely. Complex, atypical symptoms (e.g., hemiparesis, monocular blindness, ophthalmoplegia, or confusion), accompanied by a headache, warrant careful diagnostic investigation, including a combination of neuroimaging, electroencephalogram, and appropriate metabolic studies.
Common causes of secondary headaches include head trauma, intercurrent viral illness, and sinusitis. Medication overuse headaches may complicate primary and secondary headaches. Serious causes of secondary headache include increasedintracranial pressure (ICP) caused by a mass (tumor, vascularmalformation) or intrinsic increase in pressure (pseudotumorcerebri). Increased ICP should be suspected if the headacheand associated vomiting are worse when lying down or on firstawakening; awaken the child from sleep; remit on arising; or areexacerbated by coughing, Valsalva maneuver, or bending over.Papilledema (Figure 180-1) or focal neurological deficits such ascranial nerve VI palsy may be seen on examination.
For most children, a thorough history and physical examination provide an accurate diagnosis and obviate the need for further testing. Neuroimaging is usually not necessary. Imaging is warranted, however, when the neurologic examination is abnormal, there are unusual neurologic features during the headache, or the child has signs or symptoms of increased ICP. Focal neurological deficits, alteration of consciousness, or a chronic progressive headache pattern may warrant imaging. In these cases, brain magnetic resonance imaging, with and without gadolinium contrast, is the study of choice, providing the highest sensitivity for detecting posterior fossa lesions and other, more subtle abnormalities. When the headache has a sudden, severe onset, emergent computed tomography (CT) can quickly evaluate for intracranial bleeding. If the CT is negative, a lumbar puncture should be performed, with measurement of opening pressure and evaluation for red and white blood cells, protein, glucose, or xanthochromia.
Figure 180-1 Papilledema with dilation of the vessels, obliteration of the optic cup, loss of disc margin, and hemorrhages around disc. (From Kliegman RE, Behrman, RM, Jenson HB, editors: Nelson Text-book of Pediatrics, ed 18, Philadelphia, 2007, Saunders, p 2107.)