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