2 History Taking of Common Pediatric Cases
2.24 Headache
• Headache is a common complaint in pediatrics, especially in older children and adolescents [63, 64].
• It can be classified into:
– Primary headaches are often recurrent and episodic (e.g., migraine, tension- type, and cluster headaches). There is no underlying cause.
– Secondary headaches are a symptom of an underlying intracranial or medi-cal condition (e.g., tumor or trauma) (see Table 2.6) [64].
• Headaches may also be classified in terms of time course, into:
– Acute headache (e.g., intracranial hemorrhage, infections: meningitis, sinus-itis, pharyngsinus-itis, otitis media)
– Acute recurrent headache (e.g., migraine, cluster headache, or hypertension)
– Chronic progressive headache (e.g., neoplasm, abscess, hydrocephalus, pseudotumor cerebri)
– Chronic nonprogressive headache (e.g., tension-type headache, chronic sinus-itis, ocular disorder, medication-overuse headache, psychosomatic) [37, 64]
• It is very important to know the warning features in childhood headache (see Box 2.1).
Table 2.6 Characteristic features of the common causes of both primary and secondary head-aches from the history [37, 63, 93]
Type of headache Characteristic features Examples of primary headaches
Migraine – This is an acute recurrent headache; each attack lasts for about 1–72 h
– It is characterized by a throbbing quality and a moderate-to-severe intensity
– The headache is focal unilateral or bilateral or may switch from side to side
– It is typically associated with anorexia, nausea, vomiting, pallor, light and sound sensitivity, and visual symptoms (such as flashing lights)
– It is often triggered by stress, tiredness, or specific foods
– It often occurs in the afternoon but sometimes awakens the child from sleep
– It may be relieved by a short period of sleep – It is worsened by physical activity, so it disrupts the
child’s activities
– Often there is a family history of migraines – It may occur with or without an aura (Aura is a
neurologic alarm that a migraine will take place. It consists of visual, sensory, or language symptoms that develop over 5 min and last from 5 to 60 min. These symptoms are fully reversible)
– Note: There are different types of migraines (e.g., migraine without aura, migraine with typical aura, vestibular migraine with vertigo, and chronic migraine).
For each type of migraine, there are diagnostic criteria [94]
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Table 2.6 (continued)
Type of headache Characteristic features Tension-type headaches
(TTH) – These tend to occur like a band around the head and can last for 5 min to 7 days
– They are typically bilateral with a tightening quality – They occur late in the day or may last all day – They are mild-to-moderate in intensity and diffuse
in location and are not affected by the activity – They do not interfere with sleep
– They may be associated with anxiety, depression, or a stressful environment
– There is an absence of other associated symptoms, like nausea, vomiting, or photophobia
– They are relieved by stress reduction Examples of secondary headaches
Headache of increased intracranial pressure (ICP) (e.g., neoplasm, vascular malformation, or cystic structure)
– This is a chronic progressive headache of increasing severity or frequency
– It frequently locates in the same position – It may have a throbbing, pressing, or sharp quality – It worsens by lying flat or coughing, and it is seldom
relieved by any specific factor
– It usually gets worse in the early morning and may awaken the child from sleep
– It disrupts the child’s activities
– It may result in vomiting and may cause diplopia, due to a VI cranial nerve palsy
Headache of CNS infection (e.g., meningitis and infectious encephalitis)
– This is often of acute onset
– It may be preceded by upper respiratory tract symptoms – It is associated with fever, neck or spine stiffness, focal
neurologic signs, seizures, confusion, lethargy, arthralgia, myalgia, petechial or purpuric lesions, symptoms of raised ICP (e.g., vomiting, diplopia, ptosis, and apnea)
Intracranial hemorrhage – This starts abruptly and develops rapidly
– It presents as a very severe “thunderclap”; it is often described as “the worst pain in my life”
– It may be associated with a loss of consciousness, nuchal rigidity, focal neurologic, in addition to deficits and seizures
– The child may have a condition that may possibly lead to a hemorrhagic stroke, such as coagulopathy, hemoglobinopathy, or heart disease
• Identity: Age, sex
• Chief complaint: Headache
• History of present illness:
1. Onset: Sudden or gradual
2. Duration and time course of typical headache episode: A recent or chronic headache
History Station 2.23: Headache
Continued on the next page 2.24 Headache
3. Age of onset (if chronic)
4. Timing: Daytime or nighttime? What is the child doing when a typical headache begins?
5. Location: Temporal, suboccipital, retro-orbital, unilateral, bilateral, or switching from side to side
6. Character of pain: Band-like, throbbing, dull, sharp, thunderclap 7. Frequency of the headache and duration of each episode
8. Severity and progression: Does the headache cause the child to stop play-ing or interfere with normal activity? Does it wake the child from sleep?
Does the headache become more frequent? Has it worsened or stayed the same?
9. Aura or prodrome: Blurred vision, visual scotomata, sensory distur-bances, nausea, and/or vomiting
10. Aggravating or relieving factors: Exacerbation by sounds or light, exer-cising, straining, changing position, emotional upset, foods (e.g., cheese), or menses and relief by analgesics or sleep
11. Associated symptoms: Fever, nausea, vomiting, photophobia, diplopia, eye tearing, numbness, weakness, irritability, tiredness, agitation, loud crying, neck stiffness (suggests meningitis), vertigo, loss of consciousness
12. Triggers: Specific foods, activities, tiredness, stress, or events. Does the child have an idea about what triggers the headaches?
13. Has the headache preceded by upper respiratory tract symptoms?
• Past history: Past illnesses, depression, anxiety, motion sickness, head inju-ries, or allergies
• Medication history: Analgesics use (dosage and frequency of analgesics), ergotamine, triptan, vitamin A, or birth control pills, drug allergies
• Development history: Developmental delay, growth delay
• Immunization history: Influenza vaccine, hepatitis A vaccine
• Family history: Recurrent headaches or history of migraine in the family;
parental description of their headaches; other neurologic, psychiatric, and general health conditions
• Social history: Stressful events, social withdrawal, school absences, emo-tional problems in school or at home, drug abuse, alcohol, cigarettes, travel, contact with animals
• Review of systems: Abdominal pain; diarrhea; gastrointestinal bleeding;
pallor; skin rash; joint pain; changes in personality, intellectual skills, hearing, vision, memory, gait, balance, or strength; or postural lightheadedness
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• Acute recurrent throbbing headache suggests a migraine; headache that pres-ents as a band around the head may suggest a tension headache; a thunder-clap headache suggests subarachnoid hemorrhage.
• An acute-onset severe headache needs rapid assessment as it may require a specific and urgent treatment [64].
• A chronic progressive headache requires neuroimaging evaluation since it may suggest an enlarging intracranial lesion.
Key Points 2.23
• Recent headache onset
• First or worst headache
• Occipital location
• Increasing severity or frequency
• Headache causing awakening from sleep
• Neurologic abnormalities or visual changes
• Headache in the morning, associated with vomiting
• Persistent vomiting
• Behavioral changes