Pediatric emergency medicine trisk 1136 1136
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impinging on adjacent pain-sensitive structures. The most pain-sensitive
intracranial structures are the proximal portions of the large cerebral arteries at
the base of the brain, the venous sinuses, and the large cerebral veins.
Various physiologic mechanisms come into play in causing headache. Painful
stimuli can be broadly categorized as resulting from vascular effects, muscle
contraction, inflammation, and traction/compression ( Table 59.1 ). Examples of
each of these types of headache etiology are described in the following discussion
of differential diagnosis. It should be noted that visual problems are an unlikely
cause of significant headaches in children. A child with persistent headaches that
have previously been attributed to “eye strain” may, therefore, deserve a more
careful evaluation.
Attempting to predict the neuroanatomic location of a pathologic process using
only the site of headache described by a child is unreliable. In part, this is
attributable to the unpredictable displacement of structures caused by a mass
lesion. In addition, the extremely complex relationships of the various nerves
involved in pain sensation of the head and neck lead to unexpected patterns of
referred pain. Thus, a posterior fossa lesion can cause frontal or orbital pain, and
supratentorial lesions may result in pain localized to the occiput or the back of the
neck, for example.
DIFFERENTIAL DIAGNOSIS
A comprehensive discussion of the various causes of headache in pediatric
patients is beyond the scope of this textbook. The conditions described here are
those most likely to be seen in acute- and emergency-care settings ( Table 59.2 )
and those with the greatest potential for imminent morbidity or mortality ( Table
59.3 ). Fortunately, the majority of pediatric patients who present to the ED with
headache have a benign condition. In a study of 432 children and teenagers
evaluated in the ED for headache, Conicella et al. found that the most common
etiologies were upper respiratory infection (19%), migraine (18.5%),
posttraumatic headache (5.5%), and tension-type headache (4.6%). Anatomic
abnormality (e.g., Chiari malformation), brain tumor, meningitis, idiopathic
intracranial hypertension, and ventricular shunt failure were found in a total of
6% of patients.
Vascular
Headaches associated with vascular changes are believed to be caused primarily
by vasodilation, although the exact mechanism has yet to be fully elucidated. One
common example of this type of headache is migraine. Migraine headaches are
typically chronic and remitting, with a characteristic pattern that is easily
