Headaches are common in children, increasing in incidence from early childhood to adolescence. They account for 0.7% to 1.3% of all pediatric emergency department visits. Headaches may be classified as primary or secondary. Primary headaches include migraine, tension-type, cluster, as well as the new daily persistent headache. Secondary headaches are symptomatic of an underlying intracranial or medical condition that requires treatment. The initial evaluation of acute headache aims to determine whether there is a secondary cause for headache that requires urgent intervention.
Headache may be classified in terms of time course.
A single episode of headache pain without prior headaches.
May represent the first or an unusually severe form of primary headache.
May suggest a new acute secondary cause for headache that, therefore, requires evaluation.
Acute recurrent headache
Stereotyped headaches separated by headache-free periods.
Most suggestive of a primary headache disorder, especially if the pattern has persisted for a long period.
May also occur in secondary headache, as with intermittent elevation in intracranial pressure.
Chronic progressive headache
A gradual increase in headache.
Suggestive of an expanding intracranial lesion.
Of children with brain tumors, 62% have headache prior to diagnosis, and 98% have at least one neurologic symptom or abnormality on examination.
The most common symptoms include nausea or vomiting, difficulty walking, visual symptoms, focal weakness, or personality change.
The most common signs include optic nerve edema, abnormal eye movements, ataxia, abnormal reflexes, and visual field or acuity defects.
Chronic nonprogressive headache
Constant steady headache.
May be due to a chronic type of primary headache or similar secondary etiologies.
Migraine diagnostic criteria
A: At least 5 attacks fulfilling criteria B-D
B: Headache attacks lasting 2 to 72 hours (when untreated or unsuccessfully treated) (note: compared with 4 to 72 hours in adults)
C: Headache having at least 2 of the following characteristics:
Unilateral location, may be bilateral, frontotemporal*
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity (e.g., walking, climbing stairs)
D: During the headache, at least 1 of the following:
Nausea or vomiting
Photophobia and phonophobia, which may be inferred from behavior
E: Not attributable to another disorder.
*The ICHD-3 classification notes that migraine headache in children and adolescents (aged under 18 years) is more often bilateral than is the case in adults; unilateral pain usually emerges in late adolescence or early adult life. Migraine headache is usually frontotemporal. Occipital headache in children is rare and calls for diagnostic caution.
Diagnosis of migraine with aura requires:
A: At least 2 attacks fulfilling the criteria B and C
B: 1 or more of the following fully reversible aura symptoms**:
3. Speech and/or language
C: At least 3 of the following 6 characteristics:
1. At least 1 aura symptom spreads gradually over 5 minutes
2. Two or more aura symptoms occur in succession
3. Each individual aura symptom lasts 5-60 minutes
4. At least 1 aura symptom is unilateral
5. At least 1 aura symptom is positive
6. The aura is accompanied, or followed within 60 minutes, by headache
D: Not attributable to another disorder.
**The ICHD-3 classification notes that in children and adolescents, less typical bilateral visual symptoms occur that may represent an aura.
- Subarachnoid hemorrhage
- Ischemic stroke
- Parenchymal hemorrhage
- Vascular dissection (carotid, vertebral, or intracranial arteries)
- Cerebral sinovenous thrombosis
- Postconcussion headache
- Cerebral contusion
- Subdural hemorrhage
- Intracranial hypotension
- Epidural hemorrhage
- Dental caries, gingival disease, or abscess
- Brain tumor
- Temporomandibular joint syndrome
- Tension headache
- Indomethacin-responsive headache
- Medication-overuse headache
- Cluster headache
- New daily persistent headache
- Intermittent hydrocephalus
- Pseudotumor cerebri (idiopathic intracranial hypertension)
- Ventriculoperitoneal shunt dysfunction
- Pituitary apoplexy
- Hypertensive encephalopathy
- Occipital neuralgia
- Facial neuralgia
Christopher B. Oakley, MD
Department of Child Neurology
Johns Hopkins Hospital
CBO declares that he has no competing interests.
Dr Christopher B. Oakley would like to gratefully acknowledge Dr Nicholas S. Abend and Dr Daniel J. Licht, the previous contributors to this topic.
NSA and DJL declare that they have no competing interests.
Paul Hamilton, MD
Department of Emergency Medicine
Mount Sinai School of Medicine
PH declares that he has no competing interests.
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