HEADACHE
Author: Magna Chung Dias, MD
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)
Revision Date: October 3, 2014
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

HEADACHE
Author: Magna Chung Dias, MD
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
Revision Date: October 3, 2014
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.
2.
3.
4.
Fleisher G, Ludwig S, Henretig R,
eds. Textbook of Pediatric
Emergency Medicine. 5th Edition.
Philadelphia, PA: Lippincott, 2006.
Lewis D, Qureshi F. Acute
Headache in Children and
Adolescents Presenting to the
Emergency Department. Headache
2000: 200-203.
Haslam RH. Headaches. In:
Nelson Textbook of Pediatrics. 17th
Edition. Philadelphia, PA:
Saunders Elsevier, 2004.
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