Society for Pediatric Urgent Care

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Society for Pediatric Urgent Care

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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. 5th 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. 17th Edition. Philadelphia, PA: Saunders Elsevier, 2004.
  4. Uptodate: http://www.uptodate.com