Pediatric emergency medicine trisk 1141 1141
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muscles may be tender to palpation. Although muscle contraction is an unlikely
cause of headache in younger children, the stress of life during adolescence will
often produce this type of headache. Onset is typically at the end of the day. A
headache that is present on arising in the morning or that awakens a patient from
sleep is an unusual manifestation of muscle contraction.
Inflammation
A wide variety of inflammatory conditions can result in headache, ranging from
benign to potentially life-threatening entities. Children with bacterial meningitis
or encephalitis may present with headache, although this is usually only one of a
constellation of symptoms, such as fever, lethargy, neck pain, confusion, or coma.
Headache is unlikely to be the sole complaint in these patients. However, an older
child or adolescent with viral meningitis can present with a severe headache,
mild, or sometimes no neck discomfort and no other signs of significant illness.
Fortunately, viral meningitis is generally a benign process. Rare causes of
inflammatory headache include retroorbital cellulitis or abscess and brain abscess.
Focal findings on neurologic and/or ocular examination will normally provide
clues to these unusual diagnoses.
Headaches can also be caused by inflammatory processes affecting other
structures of the head and neck. For example, pediatric patients with pharyngitis
caused by group A streptococcus will often complain of headaches. Indeed, the
classic presentation for streptococcal pharyngitis in children is sore throat, fever,
and headache, sometimes associated with abdominal pain. In a child who has
difficulty localizing pain, otitis media and otitis externa can also present as
headache. Pediatric patients with sinusitis will sometimes complain of facial or
periorbital pain, although younger children may simply have a persistent nasal
discharge. Dental abscess can be overlooked as a cause of headache because it is
a relatively uncommon finding in children. Therefore, a careful examination of
the teeth and gingiva should be performed for all pediatric patients with
unexplained headaches. Finally, inflammation of the temporomandibular joint
(TMJ) is a rare cause of unilateral headaches in children (TMJ syndrome). These
patients typically report increased pain while chewing and have point tenderness
over the mandibular condyle.
Traction/Compression
Headaches can be caused by mass effect from a pathologic lesion that produces
traction and/or compression involving pain-sensitive structures of the head and
neck. For the emergency physician, the most important conditions in this category
are intracranial hemorrhage and brain tumor. An intracranial hemorrhage
