produces displacement of surrounding tissues and, in cases of more significant bleeding, increased ICP In the pediatric population, this is most often the result of a severe head injury (see Chapter 113 Neurotrauma ) However, in rare instances, a child can have a nontraumatic intracranial hemorrhage from a ruptured vascular anomaly (e.g., an arteriovenous malformation), which leads to bleeding into the brain parenchyma and ventricles As with other vascular events, this type of hemorrhage is characterized by the abrupt onset of severe pain In contrast, headaches resulting from a brain tumor typically have a more insidious onset The child will often complain of progressively worsening headaches for several weeks or months Additional symptoms, such as persistent vomiting or gait abnormalities, may also be present Unfortunately, the physical examination can be normal during the early phase of the illness, and as mentioned previously, this commonly leads to a delayed diagnosis Other processes that cause headache as a result of traction and compression include idiopathic intracranial hypertension, brain abscess, hydrocephalus, ventricular shunt failure, and persistent spinal fluid leak after lumbar puncture An unusual cause of headache in pediatric patients that deserves special mention because of its potentially life-threatening nature is arterial dissection Patients may have a headache for hours or days before developing neurologic deficits caused by worsening vascular insufficiency and ultimately stroke The classic presentation of vertebral artery dissection is neck pain and a severe occipital headache that occurs after minor (even trivial) trauma to the neck, followed by the onset of symptoms such as ataxia, nystagmus, and unilateral weakness Although, as noted previously, nonhemorrhagic cerebral infarcts are not typically associated with headache, this is one important situation in which headache and ischemic stroke can coexist Psychogenic Although less common than in adults, headaches of psychogenic origin are also seen in children Possible causes include school avoidance behavior, malingering with secondary gain issues, and a true conversion disorder These patients often have a history of chronic headaches that have been unresponsive to various treatment methods, and they may have undergone multiple tests without receiving a diagnosis Parents of these children are usually worried and frustrated Their reasoning in coming to the ED after an extensive prior workup is often simply to get another opinion For the emergency physician, establishing definitively that a child’s persistent headaches are the result of a psychogenic cause is generally impossible Obviously, this should be considered a diagnosis of exclusion However, if the history and physical examination not suggest a more serious