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