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