Abstract
Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.
Highlights
Headache is a frequent complaint in pediatric population, even more frequent than adults
A typical element is the complete resolution of Changes in mood or personality over days or weeks Related to severe vomiting, especially in early morning Worsening of pain with cough or Valsalva maneuver Altered conscious state Papilledema Focal neurologic deficit or meningismus Seizures or fever High-risk population Pain that wakes the c.hild from sleep or occurs on waking Change of the character of headache in patients diagnosed with primary headache Poor general condition Increased head circumference Cranial nerve palsies Abnormal ocular movements, squint, pathologic pupillary responses Visual field defects Ataxia, gait abnormalities, impaired coordination Sudden onset of headache Increase in severity or characteristics of the headache Occipital headache* Age < 5 years*
The authors concluded that awakening or sleep interruption due to headache among clinically well and neurologically normal pediatric patients was most likely to be caused by primary headaches, migraine or tension type headaches, and this needs to be more widely recognized in order to avoid unnecessary brain imaging
Summary
Headache is a frequent complaint in pediatric population, even more frequent than adults. There has been a substantial increase in the incidence of childhood migraine and headache over the last 30 years. The individual and social costs of pediatric headache disorders are due to the high incidence, frequency, and lifetime prevalence of these conditions [6]. Frequency is higher in males before puberty and in females after puberty [10] Another important consideration is that 35% of children with headache present to an emergency department (ED) at least once a year for any reason, compared with 17% of the general pediatric population [11]. Differential diagnosis of pediatric headache in the ED includes a variety of benign causes and viral infections, sinusitis, migraine, and post-traumatic headaches are the most common diagnoses [2]. The identification of factors associated with LT secondary headache (red flags), the identification of causes of LT headaches and the rational use of laboratory tests and diagnostic imaging are discussed
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