Pediatric emergency medicine trisk 1145 1145
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history may not always be reliable. A youngster who is smiling and playing with
toys may nod “yes” in response to the question, “Is the pain very, very bad?” In
such cases, the description of the severity of pain must obviously be correlated
with the child’s clinical appearance. Questions about the quality of pain (e.g.,
boring, throbbing) are often less useful in children.
The frequency and duration of headaches can also provide valuable clues about
the origin of the pain. A child who complains of a constant headache for several
days without respite (i.e., goes to sleep with it, wakes up with it) usually has a
tension headache or, perhaps more likely, a psychogenic headache. In general,
headaches that become progressively more frequent or prolonged should raise
suspicion for a more serious underlying condition. Similarly, a child with
headaches that have steadily worsened in severity over time warrants careful
evaluation, again given the limitations of a child’s description of pain. Parents can
often help clarify such situations. For example, they may report that the child
previously complained of headaches while continuing to play, but now the
headaches cause the child to stop any activity, lie down, and start crying.
An important exception to the generally benign nature of headaches that are
described as constant over prolonged periods is the rare patient who presents to
the ED with undiagnosed idiopathic intracranial hypertension. Classically, an
overweight female adolescent or young adult, these patients will often complain
of severe, unrelenting headache that may gradually worsen over a period of
several days. These patients are easily misdiagnosed as having such conditions as
sinusitis or migraine or psychogenic headache. This presentation is especially
significant if the patient also reports newly impaired vision, because this may be a
sign of excessive pressure on the optic nerves, which, if untreated, can result in
permanent vision loss.
The time and circumstances of occurrence are also important historical points
to ascertain. For example, headaches that are present when a child arises each
morning or that awaken a child at night should raise suspicion about a possible
brain tumor. In contrast, headaches that occur only later in the day are typically
related to stress and result from muscle contraction. Vascular headaches are
typically worsened by exertion. In addition, any precipitating events that
consistently cause or exacerbate a headache should be identified. If an older child
has a headache that is significantly worse when leaning down (e.g., to pick up
something off the floor), this is most likely to be caused by sinusitis, although in
rare cases, this history may be present in a child with a brain tumor.
The patient’s past medical history and family history may contribute to the
diagnosis. As mentioned previously, children with cystic fibrosis or congenital
