1

An 8-year-old boy presents to your urgent care center with a 3-day history of frontal headache, associated with fever, sore throat, nausea, and vomiting. What is the basic differential for a nontraumatic pediatric headache?

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  Primary headache: migraine, tension, cluster (in order of prevalence).

  
  
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  Secondary headache: infections (such as meningitis, upper respiratory infection [URI], pharyngitis, sinusitis, otitis media, mastoiditis), medications, idiopathic intracranial hypertension, systemic hypertension, brain tumor, nontraumatic intracranial bleed (e.g., atrioventricular [A-V] malformation), and posttraumatic headache (covered separately).

2

How is the timing of a headache important?

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  A headache may be acute, acute-recurrent, chronic-progressive, or chronic-nonprogressive.

  
  
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  Chronic-progressive headaches are those that may be indicative of a gradual increase in intracranial pressure and warrant concern of space-occupying lesions.

3

What is the appropriate physical exam for a headache?

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  Neurologic exam is essential. Six critical findings with headache: papilledema, ataxia, hemiparesis, abnormal eye movements, depressed reflexes, altered mental status.

  
  
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  Exam to support secondary headache:

  
  
  
  
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    Vital signs: fever, tachycardia or bradycardia, hypertension, orthostatic changes.

    
    
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    General: findings to suggest dehydration (tacky or dry mucous membranes, decreased or absent tears, delayed capillary refill, reduced perfusion, decreased skin turgor).

    
    
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    Head, ears, eyes, nose, and throat (HEENT): findings supporting URI, otitis media, sinusitis, streptococcal pharyngitis, dental etiology; mydriasis or nystagmus to support toxicologic etiology; papilledema or anisocoria, or cranial nerve palsy suggesting increased intracranial pressure; scalp hematoma to suggest trauma.

    
    
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    Neck: meningismus, thyromegaly, carotid bruit, torticollis.

    
    
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    Skin: neurocutaneous disorders (e.g., café-au-lait spots), Lyme disease (erythema migrans), petechiae or purpura (invasive bacterial infection).

  
  

4

A 15-year-old girl presents to your urgent care center with right-sided, pulsating headache intermittently for 3 days that worsens with bright lights and loud sounds. What constitutes a migraine headache without aura?

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  Lasts 2–72 hours.

  
  
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  Usually frontal, pulsating, moderate to severe in pain intensity, aggravated by routine physical activity.

  
  
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  Usually bilateral in childhood, may transition to unilateral in adolescents/adults.

  
  
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  Nausea/vomiting, photo- or phonophobia.

5

What is a migraine with aura?

A fully reversible focal visual, sensory, speech, motor, brainstem, or retinal attack that lasts for 5–60 minutes and is accompanied by or followed by a headache within 60 minutes of onset.

6

What is a tension headache?

A headache that is mild to moderate in intensity and usually bilateral. It may be associated with photo- or phonophobia but not usually vomiting.