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