cause of headaches, the best management approach is to communicate genuine concern about the patient, attempt to allay some of the parental fears, and plan appropriate outpatient follow-up EVALUATION AND DECISION As stated previously, the diagnosis for pediatric patients presenting with headache will be evident in all but a small minority of cases after a thorough history and physical examination Laboratory tests and imaging modalities are rarely needed Even if a definitive diagnosis cannot be established immediately, the identification of a potentially life-threatening cause of headaches will almost always be possible before the child leaves the ED Concern about the possibility of a more serious cause warrants aggressive use of whatever diagnostic or therapeutic interventions are indicated, such as a computed tomography (CT) or magnetic resonance imaging (MRI) of the head, lumbar puncture, or intravenous antibiotics Occasionally, a child with a suspected brain tumor will be appropriately discharged from the ED without undergoing any diagnostic tests Such a disposition assumes that proper follow-up for such patients can be arranged and that MRI of the head will be performed as an outpatient An approach to the diagnostic evaluation of a child with headaches is outlined in Figure 59.1 Clinical Assessment History Before proceeding to specific questions about headache symptoms, the clinician should inquire about the general health of the patient, particularly during the hours leading up to the current presentation For example, the presence of a high fever, decreased activity, and poor oral intake are suggestive of a serious inflammatory cause such as meningitis A patient with these same symptoms who also has an abrupt change in mental status may have encephalitis If a child has been relatively well but has complained of headache associated with persistent nasal discharge, this may be caused by a sinusitis A child with tooth pain, ear pain, or sore throat may also have a readily apparent reason for headaches