Majority of children are diagnosed with viral illness or migraine in the ED/UC setting.
Infection: viral meningitis, bacterial meningitis, orbital or cerebral abscess.
Tumor: isolated headache is a rare manifestation of a brain tumor.
Intracranial hemorrhage: non-traumatic (not typically HA alone)
Carbon monoxide poisoning
Hypertension: essential, pheo
Common secondary causes:
- viral meningitis
- pharyngitis (including strep)
- OM, sinusitis, dental infection
- menstrual migraine (catamenial)
- hemiplegic (unilat weakness w migraine, it’s the “motor aura” with the migraine) – this is a familial condition related to known genes
- migraine with brainstem aura (formerly “basilar-type” migraine) – vertigo, dysarthria, tinnitus, diplopia, paresthesias, decreased LOC.
- retinal migraine (rare) – vision can be permanently lost, retinal exam abnormal during attack
- cyclic vomiting syndrome
- abdominal migraine (HA not prominent) – N/V, pallor, protracted vomiting NOT common (think CVS)
- Worrisome history: wakes from sleep, fever, neck pain, vomiting, behavior changes, vision changes.
- Physical exam: Palpate everything – head, TMJ, sinuses, etc. Skin – look for rashes, cafe au lait spots, ash leaf spots. Neuro – always do a fundoscopic exam!
- Neuroimage if: first HA of its type, chronic progressive HA, age < 3 with unexplained severe HA, skin lesions suggestive of neurocutaneous syndrome, abnormal neuro exam.
- LP: see handout for indications and studies.
See Children’s Hospital slides for RED FLAGS and other useful information.
For migraine prophylaxis in kids: cyproheptadine (but take care in obese kids – it’s an appetite stimulant) is first line!