described by the patient or parents (see Chapter 97 Neurologic Emergencies ) Often, a strong family history of migraines is present For the emergency physician, the main issue with migraine patients is generally pain control, because the diagnosis is already known However, a significant change in the quality, severity, or timing of headaches in these patients may represent a separate and potentially more serious problem In such cases, the clinician should not be dissuaded by the existing diagnosis from pursuing an appropriate workup as indicated Headaches accompanying fever are also believed to be mediated by vascular effects Because fever is such a common symptom, this is probably the most common cause of headaches in pediatric patients seen in the ED Hypertension, although rare, is another possible cause of vascular headaches in children Renovascular disease leading to hypertension can in some instances be a lifethreatening etiology Additionally, children and teenagers may have an undiagnosed coarctation of the aorta leading to hypertension and associated headaches Because of its rarity, this condition is easily misdiagnosed Hypertension causes not only global changes in cerebral vasculature, but also possibly a component of increased intracranial pressure (ICP) that leads to headache TABLE 59.1 PATHOPHYSIOLOGIC CLASSIFICATION OF HEADACHES I Vascular A Febrile illness B Migraine C Systemic hypertension D Hypoxia E Caffeine withdrawal II Muscle contraction (tension) III Inflammation A Intracranial infections Meningitis Encephalitis Brain abscess B Pharyngitis C Upper respiratory infection D Dental infection E Sinus infection F Retroorbital cellulitis/abscess IV Traction/compression A Brain tumor B Intracranial hemorrhage C Increased intracranial pressure Cerebral edema Hydrocephalus Idiopathic intracranial hypertension D Brain abscess E Lumbar puncture F Arterial dissection V Posttraumatic VI Psychogenic TABLE 59.2 COMMON CAUSES OF HEADACHE Vascular Febrile illness Migraine Inflammatory Pharyngitis Upper respiratory infection Sinus infections Dental infections Muscle contraction Tension-type headache Posttraumatic Psychogenic TABLE 59.3 LIFE-THREATENING CAUSES OF HEADACHE Vascular Hypertension Hypoxia Coarctation of the aorta Stroke Inflammatory Meningitis Encephalitis Ventricular shunt infection Traction/compression Brain tumor Intracranial hemorrhage Hydrocephalus Cerebral edema Brain abscess Arterial dissection Ventricular shunt failure Environmental Carbon monoxide poisoning Finally, hypoxia is a potent stimulus for cerebral vasodilation and can produce headaches on that basis Therefore, children who experience a hypoxic insult (e.g., carbon monoxide poisoning) or those with disease states that predispose to hypoxia (e.g., cystic fibrosis, cyanotic heart disease) may present with headaches resulting from an acute process or an exacerbation of an underlying illness Muscle Contraction Headaches can be caused by contraction of the scalp or neck muscles This is the classic “tension” headache that is common in adults These headaches usually occur when a patient has experienced prolonged mental or emotional stress or desk work with inadequate attention to ergonomic factors This leads to recurrent episodes of muscle tension and/or spasm, which cause muscle soreness The patient can often localize a specific site where the pain is felt, and the involved