Pediatric emergency medicine trisk 1135 1135
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CHAPTER 59 ■ PAIN: HEADACHE
DENIS R. PAUZé, CHRISTOPHER MALABANAN
INTRODUCTION
Headache is a common complaint of pediatric patients in the emergency
department (ED). It is estimated that by the age of 15 years, up to 75% of children
have experienced headaches, although most are cared for at home. Headache as
an isolated complaint is a relatively unusual presentation in pediatric patients; it is
more often one of a number of symptoms, such as fever, lethargy, sore throat,
neck pain, and vomiting.
Like other challenging presentations, headache is seen with regularity and is
often benign, but in a small subset of patients, it can portend a potentially lifethreatening illness. Therefore, the primary responsibility of the emergency
physician is to make the important discrimination between “bad” headaches and
benign headaches. Fortunately, this differentiation can almost always be done
successfully after a thorough history and physical examination, and when
necessary, laboratory and radiographic tests. One notable exception to this rule,
however, is brain tumor. Although most serious illnesses that cause headache
(e.g., meningitis, encephalitis, ruptured vascular anomaly) will be readily
classified in the “bad” category, the presence of a brain tumor may not be. The
history can be subtle, and the examination is commonly unrevealing, often
leading to a delay in diagnosis. Therefore, characteristics of headaches caused by
a brain tumor are described in detail in this chapter. Above all, the key to proper
management of such patients is ensuring appropriate follow-up care.
PATHOPHYSIOLOGY
For a headache to occur, there must be a noxious stimulus that affects one or more
pain-sensitive structures. Injury to an area that is insensitive to pain, such as
nonhemorrhagic stroke, may cause significant morbidity but will not manifest as
headache. It is therefore useful to consider the sensory innervation of the head
and neck. All extracranial structures are sensitive to pain. Thus, processes that
affect the sinuses, oropharynx, scalp, or neck musculature often cause patients to
complain of headache. In contrast, certain intracranial structures are sensitive to
pain and others are not. For example, the brain, ependymal lining, choroid plexus,
and much of the dura and pia-arachnoid over the hemispheres are insensitive to
pain. Pathologic processes affecting these areas can cause headache, but only by
