history may not always be reliable A youngster who is smiling and playing with toys may nod “yes” in response to the question, “Is the pain very, very bad?” In such cases, the description of the severity of pain must obviously be correlated with the child’s clinical appearance Questions about the quality of pain (e.g., boring, throbbing) are often less useful in children The frequency and duration of headaches can also provide valuable clues about the origin of the pain A child who complains of a constant headache for several days without respite (i.e., goes to sleep with it, wakes up with it) usually has a tension headache or, perhaps more likely, a psychogenic headache In general, headaches that become progressively more frequent or prolonged should raise suspicion for a more serious underlying condition Similarly, a child with headaches that have steadily worsened in severity over time warrants careful evaluation, again given the limitations of a child’s description of pain Parents can often help clarify such situations For example, they may report that the child previously complained of headaches while continuing to play, but now the headaches cause the child to stop any activity, lie down, and start crying An important exception to the generally benign nature of headaches that are described as constant over prolonged periods is the rare patient who presents to the ED with undiagnosed idiopathic intracranial hypertension Classically, an overweight female adolescent or young adult, these patients will often complain of severe, unrelenting headache that may gradually worsen over a period of several days These patients are easily misdiagnosed as having such conditions as sinusitis or migraine or psychogenic headache This presentation is especially significant if the patient also reports newly impaired vision, because this may be a sign of excessive pressure on the optic nerves, which, if untreated, can result in permanent vision loss The time and circumstances of occurrence are also important historical points to ascertain For example, headaches that are present when a child arises each morning or that awaken a child at night should raise suspicion about a possible brain tumor In contrast, headaches that occur only later in the day are typically related to stress and result from muscle contraction Vascular headaches are typically worsened by exertion In addition, any precipitating events that consistently cause or exacerbate a headache should be identified If an older child has a headache that is significantly worse when leaning down (e.g., to pick up something off the floor), this is most likely to be caused by sinusitis, although in rare cases, this history may be present in a child with a brain tumor The patient’s past medical history and family history may contribute to the diagnosis As mentioned previously, children with cystic fibrosis or congenital heart disease may have headaches caused by worsening hypoxia Likewise, a patient with renal disease may develop headaches in response to an elevated blood pressure Patients with neurofibromatosis, Down syndrome, a familial cancer, or previous therapy for leukemia are all at higher risk for developing brain tumors For the child with a stable pattern of chronic, remitting headaches, the most important question regarding family history is whether anyone has had migraine headaches It should be remembered, however, that many people use the term migraine rather broadly to refer to any type of severe headache Therefore, the clinician may find it useful to describe typical migraine symptoms before questioning parents about this aspect of the history Abrupt onset of headache and nausea in several members of one household (or headache and syncope in a child) may be the result of carbon monoxide poisoning Before leaving this subject, it is worth reemphasizing the importance of a thorough history in developing an appropriate clinical suspicion of a possible brain tumor The time between onset of headaches and detection of abnormal physical findings is highly variable Making a presumptive diagnosis of brain tumor as a likely cause of headaches during this early stage of the illness will, therefore, depend entirely on the history In their classic article, Honig and Charney described several historical points that are characteristic of children with brain tumor headaches ( Table 59.4 ) Although no single pathognomonic response on history unerringly establishes the diagnosis, eliciting one or more of these findings should certainly raise the level of concern that a child’s headaches may be caused by a brain tumor TABLE 59.4 CHARACTERISTIC HISTORICAL FINDINGS OF BRAIN TUMOR HEADACHES IN CHILDREN Nocturnal headache or pain on arising in the morning Worsening over time (severity, frequency, and/or duration) Associated with vomiting, especially if vomiting gets progressively worse (vomiting may also occur with migraine) Behavioral changes Polydipsia/polyuria (craniopharyngioma) History of probable neurologic deficits (e.g., ataxia/incoordination/“clumsiness,” blurred vision, or diplopia) Reproduced with permission from Honig PJ, Charney EB Children with brain tumor headaches: distinguishing features Am J Dis Child 1982;136:121–141 Copyright © 1982 American Medical Association All rights reserved Physical Examination Finding an abnormality on the physical examination of a child with headaches will be a relatively rare event Nevertheless, a thorough examination should be performed in every case because identification of even a subtle finding (e.g., early papilledema) can significantly alter the course of evaluation and treatment As with all children seen in the ED, the first step of the examination is to assess the patient’s appearance Does the child look sick or well? Is he/she drowsy? Does the child appear to be in severe pain, mild pain, or no pain at all? A child who appears ill may have a more serious underlying condition, such as meningitis or an intracranial hemorrhage, requiring a rapid examination and prompt initiation of treatment The vital signs should also be assessed, particularly the temperature and blood pressure Although omitting the blood pressure is acceptable for many pediatric conditions, this is never acceptable for a patient with headaches Significant hypertension, usually resulting from undiagnosed renal disease or an undiagnosed coarctation of the aorta, is a rare but potentially dangerous cause of headaches that can affect children of any age For any patient with headache who complains of associated visual impairment, formal (age-appropriate) visual acuity testing should be performed Measuring basic growth parameters for a pediatric patient with headaches can also provide valuable information Macrocephaly may be the result of hydrocephalus or a brain tumor, and short stature can be associated with a craniopharyngioma that causes impaired pituitary function The head and neck examination will sometimes reveal an obvious source of headache in a child The scalp and skin should be examined for evidence of head injury Even when no history of trauma exists, the child may have had an unwitnessed event, or the history may be intentionally misleading with a victim of nonaccidental trauma Tenderness of the scalp or neck muscles is often present with headaches resulting from stress and muscle contraction The eyes should be examined to detect any abnormalities in pupillary responses or extraocular movements A sluggish pupil may be caused by an expanding mass lesion that is compressing the third cranial nerve, and pain with extraocular movements may be elicited with a retroorbital cellulitis or abscess The fundi should be carefully examined for signs of papilledema, which would suggest an elevated ICP If necessary, a short-acting dilating eye drop such as tropicamide (Mydriacyl) can be administered to facilitate the examination The clinician may find an otitis media or otitis externa Streptococcal pharyngitis as a cause of headaches may be evident as swelling, erythema, and exudates of the tonsillar pillars Facial tenderness and erythema are sometimes seen in children with maxillary or frontal sinusitis The teeth and gingiva should be examined for evidence of inflammation or abscess Nuchal rigidity can be a sign of meningitis, intracranial hemorrhage, or in rare cases, a brain tumor If a child has a ventricular shunt, assessment of shunt function should be performed when appropriate (see Chapter 122 Neurosurgical Emergencies ) Examining the skin is also important for the child with headaches Because the skin and central nervous system have a common embryologic origin, cutaneous lesions are sometimes seen with neurologic disorders For example, a child with numerous hyperpigmented spots scattered over the body (café au lait spots) most likely has neurofibromatosis This is a specific risk factor for brain tumors Similarly, children with tuberous sclerosis will almost always have several small, hypopigmented spots (ash leaf spots) that are more apparent when viewed under a Wood ultraviolet lamp Every child with a complaint of headaches needs a complete neurologic examination Any new focal finding suggests the presence of a focal lesion, such as a tumor, hemorrhage, or in rare cases, stroke The findings of a large metaanalysis regarding the frequency of presenting complaints and physical findings of children with brain tumors are listed in Table 59.5 and those specifically for children under years of age are listed in Table 59.6 Some children with migraine headaches develop focal neurologic abnormalities as part of their migraine syndrome (e.g., ophthalmoplegia), but parents can normally confirm that this is not a new problem As mentioned previously, the mental status of a ... the temperature and blood pressure Although omitting the blood pressure is acceptable for many pediatric conditions, this is never acceptable for a patient with headaches Significant hypertension,... (age-appropriate) visual acuity testing should be performed Measuring basic growth parameters for a pediatric patient with headaches can also provide valuable information Macrocephaly may be the result