Headache

Nicholas S. Abend

Donald Younkin

INTRODUCTION

Headaches are common in children and adolescents. The incidence increases from early childhood to adolescence. Headaches may be classified as primary or secondary (Table 38-1). Primary headaches are diagnosed based on groupings of symptoms and signs, and include migraine, tension-type, and cluster headaches. Secondary headaches are symptomatic of an underlying intracranial or medical condition. Headaches may also be classified in terms of time course (Figure 38-1). In acute headache, there is a single episode of headache without prior headaches. In acute recurrent headache, there are stereotyped headaches separated by headachefree periods. In chronic progressive headache, there is a gradual increase in headache intensity. In chronic nonprogressive headache, there is a constant steady headache.

DIFFERENTIAL DIAGNOSIS LIST

Acute Headache

Intracranial hemorrhage—subarachnoid, intraparenchymal, subdural, epidural

Meningitis/encephalitis

Infections: Sinusitis, pharyngitis, otitis media

First migraine, tension-type, or cluster headache

Febrile illness-related headache (often related to upper respiratory tract infection)

Dental or Temporo-Mandibular Joint dysfunction

Hydrocephalus

Vasculitis

Intracranial hypertension—primary (pseudotumor) or secondary

Intracranial hypotension

Arterial ischemic stroke

Neoplasm

Hypertension

Ventriculo-peritoneal shunt malfunction

Toxins (carbon monoxide, lead)

Acute Recurrent Headache

Migraine or tension-type headaches

Episodic intracranial hypertension (i.e., ventricular tumor)

TABLE 38-1 Simplified International Classification of Headache Disorders

Primary headache
Migraine
Migraine without aura
Migraine with aura
Hemiplegic migraine (familial or sporadic)
Basilar-type migraine
Childhood periodic syndromes that are commonly precursors of migraine
	Cyclic vomiting, abdominal migraine, benign paroxysmal vertigo of childhood
Retinal migraine
Complications of migraine
	Chronic migraine, status migrainosus, migrainous infarction
Tension headache
	Episodic or chronic
Trigeminal autonomic cephalalgias
	Cluster Headache
	Paroxysmal hemicrania (episodic of chronic)
	Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing
Chronic headaches
	New daily persistent headache
	Medication overuse headache
	Transformed migraine or tension headache
	Hemicrania continua
Others
	Exertional, cough, stabbing, hypnic, primary thunderclap
Secondary headache
Acute and chronic posttraumatic headache
Headache attributed to intracranial hematoma (traumatic or nontraumatic)
Headache attributed to head or neck trauma.
Headache attributed to cranial or cervical vascular disorders
Acute ischemic cerebrovascular disorder
Unruptured vascular malformation
Headache due to arteritis
Cerebral venous thrombosis
High CSF pressure
Low CSF pressure
Noninfectious inflammatory disorder
Headache attributed to neoplasm
Epileptic seizures
Headache due to Chiari type I malformation
Headache associated with substance abuse or withdrawal
Intracranial infection
Systemic infection
Hypoxia and or hypercapnia
Dialysis headache
Hypertension
Hypothyroidism
Fasting
Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose sinuses, teeth, and mouth

FIGURE 38-1 Temporal patterns of headache. (Adapted from Rothner AD. The evaluation of headaches in children and adolescents. Semin Pediatr Neurol. 1995; 2:109-118).

Chronic Progressive Headache

Neoplasm

Intracranial hypertension (primary or secondary)

Neoplasm

Abscess

Epidural or Subdural Hemorrhage

Vascular Malformation

Toxins (carbon monoxide, lead)

Chronic Nonprogressive Headache

Chronic daily headache

Medication overuse headache

New daily persistent headache

Psychosomatic

Post-concussion syndrome

DIFFERENTIAL DIAGNOSIS DISCUSSION

Acute Onset (Thunderclap) Headache

Thunderclap headache (or sudden severe headache onset) is uncommon, but recognition and accurate diagnosis of this headache are important because there is often a serious underlying brain disorder that requires specific and urgent therapy. These include subarachnoid hemorrhage, parenchymal hemorrhage, sinovenous thrombosis, intracranial infection, arterial dissection, pituitary apoplexy, intracranial hypotension, and intermittent hydrocephalus. After a history and physical examination, diagnostic testing often begins with a noncontrast head computed tomography (CT) in which acute blood will be bright. If subarachnoid hemorrhage is suspected and the head CT is nondiagnostic, then lumbar puncture should be performed with two tubes sent for cell count (to differentiate between subarachnoid blood in which the red blood cell count will remain constant and a traumatic tap in which the red blood cell count will decrease from tube 1 to tube 4). If arterial dissection, sinovenous thrombosis, or tumor is suspected, then MRI with and without gadolinium is indicated and may require specific sequences to visualize the neck vasculature or venous sinuses. If intracranial hypertension or hypotension is suspected, then a lumbar puncture with opening pressure is indicated. Generally, neuroimaging is indicated prior to lumbar puncture since mass lesions may pose the risk of herniation with lumbar puncture. Only after appropriate evaluation can more benign etiologies be diagnosed including first or severe migraine or tension headache, cluster headache, or exertion/coital headache.

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