Pediatric emergency medicine trisk 1143 1143
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cause of headaches, the best management approach is to communicate genuine
concern about the patient, attempt to allay some of the parental fears, and plan
appropriate outpatient follow-up.
EVALUATION AND DECISION
As stated previously, the diagnosis for pediatric patients presenting with headache
will be evident in all but a small minority of cases after a thorough history and
physical examination. Laboratory tests and imaging modalities are rarely needed.
Even if a definitive diagnosis cannot be established immediately, the
identification of a potentially life-threatening cause of headaches will almost
always be possible before the child leaves the ED. Concern about the possibility
of a more serious cause warrants aggressive use of whatever diagnostic or
therapeutic interventions are indicated, such as a computed tomography (CT) or
magnetic resonance imaging (MRI) of the head, lumbar puncture, or intravenous
antibiotics. Occasionally, a child with a suspected brain tumor will be
appropriately discharged from the ED without undergoing any diagnostic tests.
Such a disposition assumes that proper follow-up for such patients can be
arranged and that MRI of the head will be performed as an outpatient. An
approach to the diagnostic evaluation of a child with headaches is outlined in
Figure 59.1 .
Clinical Assessment
History
Before proceeding to specific questions about headache symptoms, the clinician
should inquire about the general health of the patient, particularly during the
hours leading up to the current presentation. For example, the presence of a high
fever, decreased activity, and poor oral intake are suggestive of a serious
inflammatory cause such as meningitis. A patient with these same symptoms who
also has an abrupt change in mental status may have encephalitis. If a child has
been relatively well but has complained of headache associated with persistent
nasal discharge, this may be caused by a sinusitis. A child with tooth pain, ear
pain, or sore throat may also have a readily apparent reason for headaches.
