Pediatric emergency medicine trisk 1148 1148
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The head and neck examination will sometimes reveal an obvious source of
headache in a child. The scalp and skin should be examined for evidence of head
injury. Even when no history of trauma exists, the child may have had an
unwitnessed event, or the history may be intentionally misleading with a victim
of nonaccidental trauma. Tenderness of the scalp or neck muscles is often present
with headaches resulting from stress and muscle contraction. The eyes should be
examined to detect any abnormalities in pupillary responses or extraocular
movements. A sluggish pupil may be caused by an expanding mass lesion that is
compressing the third cranial nerve, and pain with extraocular movements may be
elicited with a retroorbital cellulitis or abscess. The fundi should be carefully
examined for signs of papilledema, which would suggest an elevated ICP. If
necessary, a short-acting dilating eye drop such as tropicamide (Mydriacyl) can
be administered to facilitate the examination. The clinician may find an otitis
media or otitis externa. Streptococcal pharyngitis as a cause of headaches may be
evident as swelling, erythema, and exudates of the tonsillar pillars. Facial
tenderness and erythema are sometimes seen in children with maxillary or frontal
sinusitis. The teeth and gingiva should be examined for evidence of inflammation
or abscess. Nuchal rigidity can be a sign of meningitis, intracranial hemorrhage,
or in rare cases, a brain tumor. If a child has a ventricular shunt, assessment of
shunt function should be performed when appropriate (see Chapter 122
Neurosurgical Emergencies ).
Examining the skin is also important for the child with headaches. Because the
skin and central nervous system have a common embryologic origin, cutaneous
lesions are sometimes seen with neurologic disorders. For example, a child with
numerous hyperpigmented spots scattered over the body (café au lait spots) most
likely has neurofibromatosis. This is a specific risk factor for brain tumors.
Similarly, children with tuberous sclerosis will almost always have several small,
hypopigmented spots (ash leaf spots) that are more apparent when viewed under a
Wood ultraviolet lamp.
Every child with a complaint of headaches needs a complete neurologic
examination. Any new focal finding suggests the presence of a focal lesion, such
as a tumor, hemorrhage, or in rare cases, stroke. The findings of a large metaanalysis regarding the frequency of presenting complaints and physical findings
of children with brain tumors are listed in Table 59.5 and those specifically for
children under 4 years of age are listed in Table 59.6 . Some children with
migraine headaches develop focal neurologic abnormalities as part of their
migraine syndrome (e.g., ophthalmoplegia), but parents can normally confirm
that this is not a new problem. As mentioned previously, the mental status of a
