Pediatric emergency medicine trisk 1147 1147
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TABLE 59.4
CHARACTERISTIC HISTORICAL FINDINGS OF BRAIN TUMOR
HEADACHES IN CHILDREN
Nocturnal headache or pain on arising in the morning
Worsening over time (severity, frequency, and/or duration)
Associated with vomiting, especially if vomiting gets progressively worse
(vomiting may also occur with migraine)
Behavioral changes
Polydipsia/polyuria (craniopharyngioma)
History of probable neurologic deficits (e.g.,
ataxia/incoordination/“clumsiness,” blurred vision, or diplopia)
Reproduced with permission from Honig PJ, Charney EB. Children with brain tumor headaches:
distinguishing features. Am J Dis Child 1982;136:121–141. Copyright © 1982 American Medical
Association. All rights reserved.
Physical Examination
Finding an abnormality on the physical examination of a child with headaches
will be a relatively rare event. Nevertheless, a thorough examination should be
performed in every case because identification of even a subtle finding (e.g., early
papilledema) can significantly alter the course of evaluation and treatment. As
with all children seen in the ED, the first step of the examination is to assess the
patient’s appearance. Does the child look sick or well? Is he/she drowsy? Does
the child appear to be in severe pain, mild pain, or no pain at all? A child who
appears ill may have a more serious underlying condition, such as meningitis or
an intracranial hemorrhage, requiring a rapid examination and prompt initiation
of treatment.
The vital signs should also be assessed, particularly the temperature and blood
pressure. Although omitting the blood pressure is acceptable for many pediatric
conditions, this is never acceptable for a patient with headaches. Significant
hypertension, usually resulting from undiagnosed renal disease or an undiagnosed
coarctation of the aorta, is a rare but potentially dangerous cause of headaches
that can affect children of any age. For any patient with headache who complains
of associated visual impairment, formal (age-appropriate) visual acuity testing
should be performed. Measuring basic growth parameters for a pediatric patient
with headaches can also provide valuable information. Macrocephaly may be the
result of hydrocephalus or a brain tumor, and short stature can be associated with
a craniopharyngioma that causes impaired pituitary function.
