Headache



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.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Sep 14, 2016 | Posted by in PEDIATRICS | Comments Off on Headache

Full access? Get Clinical Tree

Get Clinical Tree app for offline access