Pediatric Primary Headache From A to Z

William T. Basco, Jr., MD, MS


June 24, 2015

In This Article

The Latest in Evaluation of Headache in Children

History and Physical Examination

Dr Meghan Candee spoke about the evaluation of pediatric headache, beginning with a headache history. One of the first items of business is deciding whether the patient has primary or secondary headache. A history of trauma or other inciting event (secondary headaches) might indicate that the headache should be approached using a different clinical pathway from that of primary headaches. The focus of this presentation was on primary headaches, possibly the most vexing to pediatric providers.

After it is determined that the headache is primary, the second factor is whether the headache is merely a nuisance or is causing functional impairment in the child or family. The pattern of headache becomes very important in making this decision. What is the frequency of headaches, and are they constant or episodic? Does the headache fall into the category of "chronic daily" (occurring > 15 days per month) or new persistent headache?

The clinician should take a detailed history of medication use. Over-the-counter pain medications, notably nonsteroidal anti-inflammatory drugs (NSAIDs), can induce headaches and lead to a cyclical pattern of worsening headaches and increasing use. The clinician should also elicit any history of such comorbid conditions as anxiety, psychological trauma, motion sickness, anorexia, obesity, anxiety, or learning disabilities. Such factors as the onset of the headache, its location and quality, and the presence of an aura or other associated symptoms can help categorize the headache.

The patient will not usually mention a history of aura unless the clinician asks about it. Auras can vary from sensations to visual or auditory symptoms.

Many patients will not be able to properly identify headache triggers, so a headache diary might be helpful. Lifestyle issues, especially poor sleep hygiene, can be key contributors. Hydration status, whether the child engages in exercise, intentional or unintentional fasting (ie, skipping breakfast after waking up late and having to rush to school), and the presence of stressors should all be ascertained, including a detailed history of school performance. Does the headache affect school attendance? What is the child's caffeine or other medication intake, and is it related to the headache?

Finally, family history can be helpful in elucidating headache type. The mnemonic SMART—sleep, meals, activity, relaxation, and triggers—was developed at Seattle Children's Hospital and can be helpful in guiding the history.

Red flags that might be uncovered in the history include diplopia, loss of peripheral vision, tinnitus, morning headaches or headaches upon waking, a positional component, confusion, or swallowing difficulties. The clinician should place some weight on any complaint that the patient's headache is the "worst headache of his or her life."

Examination recommendations include measuring the blood pressure, head circumference, and body mass index. Particular attention should be paid to the presence of a heart murmur, which could suggest anemia. However, the bulk of the physical examination should focus on neurologic findings, including visual field examinations, cranial nerve testing, peripheral nerve testing (tone; symmetry; and reflexes, especially hyperreflexia), sensory loss, and evidence of ataxia.


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