Headache

ALERTS

• Cerebral anuerysm
• Meningitis
• Encephalitis
• Abscess
• Brain Tumor
• Sinus Venous Thrombosis

AGE CONSIDERATIONS

• Toddlers: may manifest as irritability
• Unusual complaint in younger children

DIFFERENTIAL DIAGNOSIS

• Tension
• Migraine
• Cluster
• ENT infection (otitis, sinusitis pharyngitis, viral infection,etc)
• Meningitis
• Psychogenic
• Seasonal allergies
• Vision change- need for glasses
• Brain tumor
• Pseudotumor
• Hypertension
• Toxins (Carbon monoxide, medications, drugs)
• Head trauma
• CNS bleed
• Depression
• Oral (Dental abscess, Temporomandibular joint strain)

EVALUATION

HISTORY

• General health, fever, poor PO (meningitis)
• Mental status (encephalitis)
• Nasal discharge, tooth pain (sinusitis, dental infection)
• Abrupt onset, extreme pain (ruptured AVM, subarachnoid)
• Frequency and duration (steadily worsening more concerning)
• Timing and circumstances (present on waking or awakening from sleep raises concern for tumor), tension headaches occur most frequently during the school day (tension)
• History of trauma
• Aura, relationship to food ingestion (migraines)
• Associated vomiting

PHYSICAL EXAM

• General appearance: sick or well?
• Blood pressure
• Meningeal signs
• Head and neck exam
• Complete neurologic exam including fundoscopic exam: are there any focal findings, such as ataxia, hemiparesis, papilledema
• Vision

CONCERNING FINDING

• Brain tumor red flags: nocturnal headache or pain on arising in the morning, worsening over time, associated with vomiting, behavioral changes, polydipsia/ polyuria, history of neurologic deficits (clumsiness, diplopia, et).
• Occipital pain: concern for posterior fossa tumors (studies have found to be statistically significant).
• Migraine can be associated with nausea and vomiting.
• Some children with migraines may develop focal neurologic findings as a part of their migraine syndrome
• Acute recurrent pattern with symptom free intervals can be seen with migraine, tension headache, cluster headache, neuralgias.
• Toddlers cannot communicate headache, but symptoms may consist of irritable, vomiting, photophobia

DIAGNOSTICS TEST

• Should not be needed for routine headache
• Consider transfer if LP or CT is needed for diagnosis

MANAGEMENT

TRANSFER/ADMIT CONSIDERATIONS

• Consider if meningitis, aneurysm, psuedotumor, brain tumor or increased ICP are being considered

REFERRAL

• Neurology: chronic headaches, unclear etiology, focal neurologic deficits
• Ophthalmology

TENSION HEADACHE

Treatment

• Benign: Tylenol, ibuprofen

Discharge Criteria

• Pain controlled with PO medications
• Able to tolerate PO

Follow Up

• Primary care physician
• Encourage fluids

Prognosis

• Very good

Anticipatory Guidance

• Treat early when headache starts
• Return if looks ills, worsening, stiff neck, vomiting, fever

MIGRAINE

• Consider if this is in the scope of practice for your urgent care

Treatment

• Analgesics (Tylenol, Ibuprofen, Ketorolac), Antiemetics (Reglan, Compazine, Zofran), Antimigraine (Sumatriptan, Ergotamines)
• Lower lights and decrease noise level

Discharge Criteria

• Pain controlled with PO medications
• Able to tolerate PO

Follow Up

• Primary care physician
• Encourage fluids
• Medications as indicated
• Avoid stimuli (for migraines, stress, fatigue, anxiety, known food triggers)

Prognosis

• Generally very good
• Migraine: 50% undergo spontaneous remission, as adults 5-10% of men and 10-20% of women have migraines

Anticipatory Guidance

• Return if headache is not controlled with po meds,looks ills, worsening, stiff neck, vomiting, fever
• Encourage sleep

PSUEDOTUMOR

• Consider if this is in the scope of practice for your Urgent Care

MANAGEMENT

• LP with opening pressure
• CSF removal

REFERENCES

1. Fleisher G, Ludwig S, Henretig R, eds. Textbook of Pediatric Emergency Medicine. 5^th Edition. Philadelphia, PA: Lippincott, 2006.
2. Lewis D, Qureshi F. Acute Headache in Children and Adolescents Presenting to the Emergency Department. Headache 2000: 200-203.
3. Haslam RH. Headaches. In: Nelson Textbook of Pediatrics. 17^th Edition. Philadelphia, PA: Saunders Elsevier, 2004.
4. Uptodate: http://www.uptodate.com