The physician should be aware of which cranial structures are sensitive to pain when trying to exclude secondary headaches. Pain-sensitive structures are the skin, periosteum, and aponeuroses. In the field of ENT, pain-sensitive structures are the nasal conchae, the various sinuses, and the ear. The eyes are pain sensitive as are the dura mater, arachnoidea, and the cerebral vessels, but not so the greater part of the brain itself, where nociceptors are missing. The posterior cranial fossa and its content are sensibly innervated by the upper ipsilateral cervical roots via the glossopharyngeal and the vagus nerve. The middle and the anterior cranial fossae are innervated by the ipsilateral trigeminal nerve. By experimental stimulation of the C1 root, pain sensation is provoked in the area of the ipsilateral eye, and frontally, which shows that those areas are obviously innervated by C1.

This knowledge allows for the pinpointing of the causes of pain. In most children with headache, there is no physical cerebral correlate. The goal is to identify those patients with secondary headache who will benefit from causal therapy.

One should take into account:

Apart from the neurological examination in headaches of so-far-unknown origin, an EEG and an ophthalmologic examination are often indicated, including testing visual acuity and papilledema in order to exclude the possibility of increased cerebral pressure. Adequate equipment and expertise allow for a sonography of the papilla and the eyeball. Medical imaging (computer tomography; MRI) helps detect anatomic anomalies, space-occupying processes, or inflammation and vascular diseases. The most appropriate procedure can best be chosen in discussion with the radiologist in order to avoid any unnecessary burden or diagnostics not leading to the results necessary for confirming hypotheses.

Abdominal pain in children is in most cases benign. But abdominal pain as a sign of an acute abdomen may indicate life-threatening diseases and may lead to permanent complaints limiting everyday activity. Since the interrelationships are complex, a physical cause should be excluded in any case of acute or chronic abdominal pain. Patients with functional abdominal pain not caused by an underlying organic disease sometimes undergo unnecessary invasive diagnostic procedures and long-­lasting inappropriate therapeutic trials or diets that are ineffective. This will make the child and his/her parents insecure; kindergarten or school is not attended regularly, and quality of life is diminished due to the pain but also due to the time spent at the doctor’s or in hospital (for details, see Sect. 4.6.1).

Characteristics of abdominal pain differ. In most cases, the child will report unspecific periumbilical pain normally attributed to functional pain (Sect. 4.6.2). In any case of sustained pain, basic diagnostics are indicated. A detailed medical history is helpful in order to get an overview of investigations already performed and to rapidly start with necessary diagnostic measures not yet performed. The following questions have proved helpful for us in the assessment of abdominal pain:

Since the abdomen is mainly connected to C-fibers, the patient is usually unable to precisely localize the painful organ. Since this is not the place to discuss the differentials of an acute abdomen, we will focus on chronic abdominal pain. Medical history and supplemental examinations are necessary in the diagnostic process. The following diseases should be excluded:

The incidence of carbohydrate malabsorption has substantially increased during the last number of years. One should know that a pathologic H2-breathing test in the absence of adequate clinical signs under exercise by no means proves a fructose or lactose malabsorption. Be aware of all the therapeutic consequences following a false-positive diagnosis. Dietary restrictions will add to the emotional burden. Balancing the risks and benefits, a diet only makes sense in our view in severe cases of carbohydrate malabsorption. By no means should a diet be prescribed in the absence of pathological clinical signs (Sect. 4.6).

Musculoskeletal pain may originate from various causes. In children, it is advisable to reconstruct the medical history, questioning the parents and the child independently. The medical history should be extended to the weeks before the onset of disease. Especially in children, it is well known that various (minor) infections may trigger reactive arthritis. There are reports of joint complaints after the use of certain antibiotics or other drugs.

(Noninvasive) joint sonography may deliver first clues to the diagnosis. Changes in the cortical bone may indicate an osteomyelitis. In case of any findings, ­sonography should be supplemented with conventional x-ray or MRI. Nontraumatic pain of the musculoskeletal system may be due to aseptic osteonecrosis (i.e., Perthes disease) or chronic nonbacterial osteomyelitis. In most cases, radiological findings will lead to the correct diagnosis. The diagnosis of juvenile idiopathic arthritis requires testing the blood chemistry (CRP, erythrocyte sedimentation rate, quantitative immunoglobulin in serum, complement system).

Generally, with back pain that is unresponsive to active measures such as training the back muscles or omitting excessive sports activities (in adolescents!), excluding a secondary cause is recommended, for instance, by doing x-ray imaging, scintigraphy of the skeleton, MRI of the affected spinal part, or blood ­chemistry (leucocytes, erythrocytes, platelets, blood smear, inflammatory parameters).

The following diseases are of importance in secondary back pain (Table 3.2).

Walker et al. (2005) demonstrated that passive coping strategies (e.g., catastrophizing, social withdrawal) are positively correlated with increased pain symptoms (e.g., pain intensity), high pain-related impairment, and increased depressive symptoms after 3 months. Adaptive strategies, such as acceptance or self-encouragement, are negatively correlated with depressive symptoms (Walker et al. 2005). A meta-analysis on cognitive-behavioral therapy (CBT) of chronic pain in childhood and adolescence found that education in active coping strategies plays a central role in CBT (Eccleston et al. 2002). This study also reports that coping strategies in childhood and adolescence are not stable over time (Gil et al. 1997). Therefore, any therapy should aim at the reduction of passive coping strategies and teach active coping strategies (Walker et al. 2005). Sections 6.4.7, 6.5.3, and 6.6.3 focus on the implementation of active coping strategies into everyday life, both on the ward and in the family. Hechler and colleagues (2010b) showed that 3 months after the inpatient therapy at the German Paediatric Pain Centre (GPPC), passive pain coping and the search for social support were reduced. Changes in coping behavior were associated with a decrease in pain intensity and pain-related disability in everyday life (Hechler et al. 2010b). Questionnaires for the assessment of ­pain-related cognition and coping strategies are the Waldron/Varni Paediatric Pain Coping Inventory (PPCI (Varni et al. 1996)), the Pain Response Inventory (PRI (Walker et al. 1997)), and the Pain Coping Questionnaire (PCQ (Reid et al. 1998)) presented in Table 3.3.