Headache

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8.6 Headache

Alistair Murray, John Ryan

Essentials

1 The primary role of an emergency physician is to exclude a significant underlying cause for a headache, most urgently that of infection, raised intracranial pressure or an intra-cerebral bleed.
2 While the majority of children with headaches presenting to the emergency department (ED) are likely to be benign, appropriate investigation and follow up of patients will ensure that serious causes are unlikely to be missed.
3 A thorough history and examination is likely to provide a diagnosis in the majority of children presenting to an ED with a headache.
4 Chronic headaches need not necessarily be investigated on an emergent basis unless they are progressive.
5 Red flags prompting further investigation of headache include: occipital headache; meningism; focal neurological signs; seizures; progressive nature; papilloedema; persistent vomiting; ataxia; presence of a ventriculoperitineal shunt; age younger than 3 years; or early morning headaches, especially those that wake the child from sleep.

Introduction

The aim of this chapter is to provide the reader with a basic understanding of the aetiology of headaches in a paediatric population presenting to an ED while offering a functional and safe approach to the management of paediatric patients with headaches. Some key points should be remembered from the outset:

• Children may require different approaches depending on factors such as age, ethnicity or socioeconomic status.
• Children under three years rarely complain of headache. This should prompt consideration of an organic cause.
• The classical history of migraine from a teenager may be more easily elicited than the history of symptoms from a shy 5-year-old.

Incidence

Approximately 1% of all presentations to emergency departments have headache as the presenting complaint.1,2. Headaches in children are very common with up to 75% of children having had a headache of some form by the age of fifteen.3 Despite the frequency, very few paediatric patients with headaches ever consult their family physician or an ED. However this does not take account of patients who present with a different complaint such as a temperature who might also have a headache as part of a concomitant illness.

Pathophysiology

The causes of headache are myriad, but the primary aim of the emergency physician should be to differentiate the patient with a headache which will run a relatively benign course, from that which may be a symptom of significant underlying pathology with immediate health implications.

The overwhelming majority of headaches will be diagnosed on history and examination alone, with little additional information arising from investigations.3–5. Furthermore, the vast majority of children that present to the emergency department with headaches are likely to be benign, but those that are not, have the potential to be life threatening.

The classification of headaches is based on the underlying aetiology.6 The International Headache Society has developed a classification of headache, the second edition of which was published in 2004 in Cephalgia and is also available on their website.7 This classifies headache into three broad categories most notably, primary or secondary headaches and cranial neuralgias central and primary facial pain and other headaches (Table 8.6.1).

Table 8.6.1 Summary of International Headache Society classification of headaches (ICHD-2)

Primary headaches Migraine Tension-type headache Cluster headaches and other trigeminal-autonomic cephalgias Other primary headaches Secondary headaches Headache attributed to head and/or neck trauma Headache attributed to cranial and/or cervical vascular disorders Headache attributed to non-vascular intracranial disorder Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homeostasis Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth or other facial or cranial structures. Headache attributed to psychiatric disorder Cranial neuralgias, central and primary facial pain and other headaches Cranial neuralgias and central causes of facial pain Other headache, cranial neuralgia, central or primary facial pain

The causes of some headaches will be dealt with in other chapters, e.g. Chapter 8.7 on meningitis, while some of the primary headache disorders will be discussed in more detail later in this chapter. We recommend an approach whereby the emergency doctor approaches each case by initially excluding the most sinister causes of the headache (Tables 8.6.2 and 8.6.3).

Table 8.6.2 Causes of headache in children
Infection
• Meningitis, encephalitis, abscess
• Influenza
• Systemic infection
• Sinusitis
• Dental infection
Vascular
• Migraine
• Intracranial haemorrhage
• Hypertensive encephalopathy
Post lumbar puncture
Raised intracranial pressure
• Brain tumour
• Hydrocephalus
• Benign intracranial hypertension
• Trauma – SDH, concussion
Toxic
• Carbon monoxide
• Lead
Functional
• Tension or cluster headache
Psychogenic
Table 8.6.3 Important causes of non-benign headache
• Brain tumours and hydrocephalus
• Benign intracranial hypertension
• Intracranial haemorrhage
• Meningitis encephalitis or abscess
• Hypertensive encephalopathy

Clinical assessment

History

The first step in any medical assessment is the history and this is no less important in the case of headache. Depending on the age of the child, the history may be taken

Onset of the headache

Sudden onset headaches can be considered differently in children compared to adults. The classical history of sudden onset headache being suggestive of subarachnoid haemorrhage in an adult is less relevant in the case of the paediatric patient. In children, the most frequent underlying cause is an upper respiratory tract infection or primary headache.2–4 There is a significantly higher proportion of underlying pathology in cases of acute headache, compared to chronic headaches. It should also be noted that the investigation of headache of acute onset is more properly the role of the emergency physician, while chronic headaches may be best investigated by the child’s general practitioner or paediatrician.

Site

Classic migraine is typically unilateral. However, the case of childhood migraine is a little different, often being bilateral. The headache of meningeal irritation due to meningitis may involve neck pain. It should also be noted that occipital headaches are relatively uncommon in children and have been reported to be an independent predictor of underlying pathology, particularly of the posterior fossa.

Pyrexia

The presence of a fever will often be reported by a parent and should immediately raise the suspicion of an infectious origin. Other inflammatory disorders may also cause a pyrexia. Equally, the absence of pyrexia does not equal the absence of an infection. In the ED, a febrile child with a headache requires consideration of the possibility of meningitis or encephalitis.

Progression

The temporal progression is of relevance in children with headaches. For example, a classic migraine will last between 1 and 72 hours in a child, while a patient with a chronic headache that is becoming progressively more severe may well have an underlying organic cause. This should prompt the emergency physician who encounters a child with such a pattern, even if incidentally, to ensure that neuroimaging is performed and that urgent appropriate follow up is arranged.5

Nature

Headache of a throbbing nature is suggestive of migraine, while band-like headaches are often tension in type. It has also been suggested that the inability of a child to describe the nature of the headache may in itself be a predictor of underlying pathology.3

Behavioural change and avoidance behaviour

This is often noted in a collateral history. While entirely non-specific, it is particularly important in raising suspicion of other causes of a headache such as a school phobia, drug misuse in the adolescent or indeed may be a pointer towards sexual assault.8

Sleep disturbance

Benign causes of headache rarely wake patients from their sleep and if a child is being woken by a headache this should prompt the consideration of further investigation or referral.

Postural symptoms

A headache that is worse on lying flat or exacerbated by coughing may be related to raised intracranial pressure. Early morning headaches after recumbency of sleep may occur with raised intracranial pressure or space occupying lesions.

Neurological deficit

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