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
