Pediatric emergency medicine trisk 1142 1142
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produces displacement of surrounding tissues and, in cases of more significant
bleeding, increased ICP. In the pediatric population, this is most often the result of
a severe head injury (see Chapter 113 Neurotrauma ). However, in rare instances,
a child can have a nontraumatic intracranial hemorrhage from a ruptured vascular
anomaly (e.g., an arteriovenous malformation), which leads to bleeding into the
brain parenchyma and ventricles. As with other vascular events, this type of
hemorrhage is characterized by the abrupt onset of severe pain. In contrast,
headaches resulting from a brain tumor typically have a more insidious onset. The
child will often complain of progressively worsening headaches for several weeks
or months. Additional symptoms, such as persistent vomiting or gait
abnormalities, may also be present. Unfortunately, the physical examination can
be normal during the early phase of the illness, and as mentioned previously, this
commonly leads to a delayed diagnosis. Other processes that cause headache as a
result of traction and compression include idiopathic intracranial hypertension,
brain abscess, hydrocephalus, ventricular shunt failure, and persistent spinal fluid
leak after lumbar puncture.
An unusual cause of headache in pediatric patients that deserves special
mention because of its potentially life-threatening nature is arterial dissection.
Patients may have a headache for hours or days before developing neurologic
deficits caused by worsening vascular insufficiency and ultimately stroke. The
classic presentation of vertebral artery dissection is neck pain and a severe
occipital headache that occurs after minor (even trivial) trauma to the neck,
followed by the onset of symptoms such as ataxia, nystagmus, and unilateral
weakness. Although, as noted previously, nonhemorrhagic cerebral infarcts are
not typically associated with headache, this is one important situation in which
headache and ischemic stroke can coexist.
Psychogenic
Although less common than in adults, headaches of psychogenic origin are also
seen in children. Possible causes include school avoidance behavior, malingering
with secondary gain issues, and a true conversion disorder. These patients often
have a history of chronic headaches that have been unresponsive to various
treatment methods, and they may have undergone multiple tests without receiving
a diagnosis. Parents of these children are usually worried and frustrated. Their
reasoning in coming to the ED after an extensive prior workup is often simply to
get another opinion. For the emergency physician, establishing definitively that a
child’s persistent headaches are the result of a psychogenic cause is generally
impossible. Obviously, this should be considered a diagnosis of exclusion.
However, if the history and physical examination do not suggest a more serious
