muscles may be tender to palpation Although muscle contraction is an unlikely cause of headache in younger children, the stress of life during adolescence will often produce this type of headache Onset is typically at the end of the day A headache that is present on arising in the morning or that awakens a patient from sleep is an unusual manifestation of muscle contraction Inflammation A wide variety of inflammatory conditions can result in headache, ranging from benign to potentially life-threatening entities Children with bacterial meningitis or encephalitis may present with headache, although this is usually only one of a constellation of symptoms, such as fever, lethargy, neck pain, confusion, or coma Headache is unlikely to be the sole complaint in these patients However, an older child or adolescent with viral meningitis can present with a severe headache, mild, or sometimes no neck discomfort and no other signs of significant illness Fortunately, viral meningitis is generally a benign process Rare causes of inflammatory headache include retroorbital cellulitis or abscess and brain abscess Focal findings on neurologic and/or ocular examination will normally provide clues to these unusual diagnoses Headaches can also be caused by inflammatory processes affecting other structures of the head and neck For example, pediatric patients with pharyngitis caused by group A streptococcus will often complain of headaches Indeed, the classic presentation for streptococcal pharyngitis in children is sore throat, fever, and headache, sometimes associated with abdominal pain In a child who has difficulty localizing pain, otitis media and otitis externa can also present as headache Pediatric patients with sinusitis will sometimes complain of facial or periorbital pain, although younger children may simply have a persistent nasal discharge Dental abscess can be overlooked as a cause of headache because it is a relatively uncommon finding in children Therefore, a careful examination of the teeth and gingiva should be performed for all pediatric patients with unexplained headaches Finally, inflammation of the temporomandibular joint (TMJ) is a rare cause of unilateral headaches in children (TMJ syndrome) These patients typically report increased pain while chewing and have point tenderness over the mandibular condyle Traction/Compression Headaches can be caused by mass effect from a pathologic lesion that produces traction and/or compression involving pain-sensitive structures of the head and neck For the emergency physician, the most important conditions in this category are intracranial hemorrhage and brain tumor An intracranial hemorrhage