Headaches in Pediatric emergency

Headache is a common symptom in children, affecting 80–90% by the age of 15. The common causes are systemic illness with fever, local ENT problems, migraine and tension headache. Meningitis, raised intracranial pressure (ICP), e.g. from tumors, and subarachnoid hemorrhage (SAH) are much rarer causes but these need to be considered. Any headaches that wake a child from sleeping or that are associated with focal signs such as a hemiplegia require investigation as an inpatient

Assessment

History

It is useful to classify headache as acute or recurrent. The following list gives the causes and key features to help make a diagnosis, based on careful history and examination:

Acute

• Systemic: fever and general illness (e.g. ’flu, pneumonia, septicemia)

• Local sinusitis, dental caries, otitis media

• Trauma: head injury

• Meningitis: reduced conscious level, toxicity, photophobia, neck stiffness

• SAH: sudden onset, severe occipital pain; possible reduced conscious level, neck stiffness

Recurrent

• Migraine: aura, nausea, vomiting, pallor, family history

• Tension: throbbing pain (involving neck muscles) at end of day

• Behavioral: family/social/school problems (may be difficult to identify)

• Raised ICP: morning headaches ± vomiting, worse with coughing/sneezing/bending

• Progressively worsening raised ICP: personality or behavioral changes, focal neurological symptoms

• Benign intracranial hypertension, systemic hypertension, uremia, recurrent hypoglycemia, recurrent seizures, lead or CO poisoning.

It may be useful to make out a possible family headache patterns diagram to help identify the nature of the headache.

Examination

As part of the examination it is important to document the following:

• ABC: blood pressure, heart rate

• General: toxic, unwell, temperature, rash

• Neurology: conscious level, fundi, visual fields, cerebellar signs, neurocutaneous stigmata, neck stiffness, cranial bruits

• Local causes: cervical lymphadenopathy, teeth, sinus, ears

• Growth and puberty: head growth, height, weight, growth velocity, pubertal status.

Investigations

In the acute situation, the two most important questions to answer are:

• Does the child need an urgent computerised tomography (CT) scan of the head? and

• Should a lumbar puncture (LP) be performed? In making the decision, you should consider the following factors:

• If the child has altered state of consciousness, focal neurological signs, raised blood pressure or papilledema, consider management of raised ICP and CT scan of head. Discuss this with senior medical staff.

• Consider LP (in the absence of the contraindications) if you are concerned about meningitis or SAH. You may need to do a CT scan first (discuss with consultant).

• If there are no symptoms and signs suggesting raised ICP/SAH/ meningitis and the story is suggestive of migraine, then treat symptomatically (see below).

• If other causes are suspected, do the appropriate investigations (e.g. septic screen, urea, carboxyhemoglobin or lead level [wrist X-rays], blood sugar profile).

Management

If there is a specific diagnosis such as meningitis, SAH, tumor, systemic infection or local infection, then treat as appropriate. Most recurrent headaches can be managed by a pediatrician and do not need to be referred to a neurologist.

Abort attack

Avoid opiates. Initially try simple oral analgesics such as paracetamol (20 mg/kg weight stat then 15 mg/kg weight per dose every 4 hours, to a maximum of 4g per day) or codeine (1 mg/kg weight per dose every 4 hours) or NSAID (ibuprofen 2.5–10 mg/kg weight per dose 6–8 hourly). For adolescents give 1 g of aspirin, 1 g of paracetamol, 10 mg of metoclopramide. Some, but not all, pediatricians use intravenous anti-emetics in severe vomiting. For example, if vomiting is a prominent feature in children over 10 years give slow i.v. prochlorperazine

(0.1–0.2 mg/kg weight).

Prophylaxis

Refer to a local doctor or general pediatric outpatient clinic for long-term management. Consider beta blockers, pizotifen or calcium channel blockers. Non-pharmacological interventions (e.g. avoidance of triggers, relaxation) often play an important role in prevention. Consider getting the child or parents to make a headache diary.

Headache patterns

It may be a good idea with the use of the chart below to explore the pattern of the child’s headaches .

• Acute recurrent includes migraine (common, classical, complicated).

• Chronic non-progressive includes tension (stress related); muscle contraction; anxiety; depression; somatisation headaches.

• Chronic progressive includes headaches from tumor; benign intracranial hypertension; brain abscess; hydrocephalus.

• Acute on chronic non-progressive includes tension headache with coexistent migraine.