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75 Headache

Headache is a very common symptom in children. Epidemiologic studies estimate that approximately 20% of children have experienced a headache by the age of 5 years, jumping to 60% to 80% by school age. There are very little data about the prevalence of headaches of a specific cause other than migraine. Overall, its prevalence is in the single digits for children ages 7 to 10 years and increases to about 20% in teens. Young children with migraines are more commonly boys, but this pattern switches at the time of preadolescence.

Clinical Presentation

Headaches have a wide variety of causes. Although many headaches are caused by primary headache syndromes, most commonly migraine and tension-type headache, an extensive history and physical examination must guide the differential diagnosis. Relevant elements of the history are listed in Table 75-1. The physical examination should include vital signs and general and neurological examinations, including visualization of the fundus. Table 75-2 outlines characteristics of many primary and secondary headaches, the recommended workup, and treatment where applicable.

Table 75-1 Headache History

Description of the headache Location and Radiation Quality of pain
Severity and school absence Frequency and duration of attacks
Pattern over time Time of day and day of week
Awaken patient from sleep  
Triggers and exacerbating factors Stress at home and school Food (MSG, caffeine, alcohol)
Sleep changes Valsalva maneuver, cough, sneeze
Posture (recumbent, upright)  
Alleviating factors Medication: clarify frequency and duration Sleep
Associated symptoms Nausea or vomiting Photo- or phonophobia
Weakness Sensory changes
Visual symptoms Lacrimation or rhinorrhea
Ptosis, pupillary changes Pulsatile tinnitus
Other Allergic symptoms Snoring or teeth grinding
Blurred vision Family history

MSG, monosodium glutamate.