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Headache is pain in the scalp and cranium. Headaches in children can be mild, refractory, or life-threatening, and can represent an acute, subacute, or chronic process. Sustained or recurrent headaches can greatly impact school performance and may even induce behavioral disturbances.1 Headache accounts for approximately 1% of all pediatric ED visits.2,3 Fortunately, most headaches in children prompting an ED visit are benign. The most common ED diagnoses for headache in children are headache associated with viral and respiratory illnesses (28.5%),2,4 post-traumatic headache (20%), headache related to possible ventriculoperitoneal shunt malfunction (11.5%), and migraine (8.5%).3 Serious causes of headache are reported in 4% to 6.9% of children and include subdural hematoma, epidural hematoma, proven ventriculoperitoneal shunt malfunction, brain abscess, pseudotumor cerebri, and aseptic meningitis.2,3 Factors correlated with dangerous conditions include preschool age, recent onset of pain, occipital location, and the child’s inability to describe the quality of the headache. Emergent neurosurgical conditions in children with headache are generally predicted by the presence of neurologic signs.5

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The pathophysiology of headaches is complex and varies according to cause. The cranium, most of the overlying meninges, brain, ependymal lining, and choroid plexus do not possess pain receptors and are thus insensitive to pain.4,6,7 However, the child may feel any painful stimulus that is extracranial or intracranial. Extracranial pain may arise from cervical nerve roots, cranial nerves, or extracranial arteries, and intracranial pain may arise from intracranial venous, arterial, or dural structures. Radiation of pain to specific areas within the head and neck is not unusual and is demonstrated by referral of cranial nerve/root pain to the occiput, ear, retroauricular areas, or throat.7,8

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Headache Classification

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Headaches are classified as primary or secondary. Primary headaches are physiologic or functional and are typically self-limited. They are often recurrent and are usually associated with normal findings on physical examination. Their diagnosis is typically based on symptoms and patterns of attack, and they include most migraine headaches, tension headaches, and cluster headaches, and many types of chronic daily headaches, such as chronic migraines. In contrast, specific causes are identifiable for secondary headaches, which are usually, but not always, anatomic in nature. These include brain tumors, vascular malformations, and intracranial abscesses; craniofacial problems, such as sinusitis, dental abscesses, or otitis; systemic disorders, such as lupus cerebritis; and exposure to toxic substances, such as carbon monoxide, lead, or cocaine. Although primary headaches can be disabling, secondary headaches are, in general, associated with greater morbidity and mortality. In order to distinguish between primary and secondary headache in children, obtain a thorough history, perform a complete physical examination, and order diagnostic tests as necessary (Table 130-1). The classification of headaches can be extremely complex, and classification aids such as those published electronically by the International Headache Society (IHS) can assist the clinician in correctly identifying the diagnostic category (http://ihs-classification.org/en/). Other classification systems are based on specific temporal patterns ...

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