Pediatric emergency medicine trisk 1146 1146
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heart disease may have headaches caused by worsening hypoxia. Likewise, a
patient with renal disease may develop headaches in response to an elevated
blood pressure. Patients with neurofibromatosis, Down syndrome, a familial
cancer, or previous therapy for leukemia are all at higher risk for developing brain
tumors. For the child with a stable pattern of chronic, remitting headaches, the
most important question regarding family history is whether anyone has had
migraine headaches. It should be remembered, however, that many people use the
term migraine rather broadly to refer to any type of severe headache. Therefore,
the clinician may find it useful to describe typical migraine symptoms before
questioning parents about this aspect of the history. Abrupt onset of headache and
nausea in several members of one household (or headache and syncope in a child)
may be the result of carbon monoxide poisoning.
Before leaving this subject, it is worth reemphasizing the importance of a
thorough history in developing an appropriate clinical suspicion of a possible
brain tumor. The time between onset of headaches and detection of abnormal
physical findings is highly variable. Making a presumptive diagnosis of brain
tumor as a likely cause of headaches during this early stage of the illness will,
therefore, depend entirely on the history. In their classic article, Honig and
Charney described several historical points that are characteristic of children with
brain tumor headaches ( Table 59.4 ). Although no single pathognomonic
response on history unerringly establishes the diagnosis, eliciting one or more of
these findings should certainly raise the level of concern that a child’s headaches
may be caused by a brain tumor.
