Paediatric headache history

This post is designed to help you remember the sorts of questions you should be asking when taking a history of headache in a child.

Harry gets lots of headaches. In the morning, his headache wakes him up and he vomits all over the bed.

This makes his mother very angry and she smacks him over the head. He doesn’t notice the warning signs that she’s coming, because he has a very stiff neck.

He tries to get out of bed, but his legs have gone all tingly. So he crawls towards the bathroom, but he can’t really find it because his vision has gone all blurry, and the bright bedroom light hurts his eyes.

He goes downstairs to have his breakfast, but it hurts when he chews, and he starts coughing and spluttering because his nose is blocked.

Finally he says he wants to take the day off school because he has a fever his tummy hurts, but when he goes to lie down, the headache just gets worse!

Questions to ask:

  • What does it feel like?
    • Tight band – tension
    • Throbbing – migraine
    • smack in the head – subarachnoid haemorrhage
  • How bad is it 1-10?
    • worst ever – SAH
  • Where is it?
    • band around head – tension
    • unilateral – migraine
    • frontal/occipital – migraine
  • Do you have any ‘warning’ signs that it’s about to happen?
    • aura – migraine
  • Does it affect your vision at all?
    • migraine
  • Do you have any other sensory/movement changes?
    • migraine – children may get abdominal migraines and complain of tummy pain
    • raised ICP
  • Have you noticed if it occurs at a particular time of day?
    • pregnancy
  • Have you had them before?
  • Have you had a fever recently?
  • Have you noticed anything that sets it off?
    • Alcohol
    • Solvents
    • Drugs
    • Menses
    • Medications – are you on any medications?
  • Is it worse when you lie down?
    • Space occupying lesion – raised ICP
  • Have you been suffering from any neck stiffness?
    • meningitis
    • raised ICP
  • Have you had any photophobia?
    • meningitis
  • Have you had any morning vomiting?
    • SOL
    • viral illness
  • Has it woken you from sleep?
    • Migraine
  • Are there any stressors at school/home (emotional angst)
  • Have you had any problems with nasal congestion?
    • Sinusitis
  • Is it worse when you chew?
    • Temporomandibular Joint discomfort
  • Have you had your vision checked recently?
    • do they wear glasses?
    • Intracranial pressure – 6th nerve palsy
    • refractive error headache
  • Have you had any head trauma recently?
  • Have you had any changes in consciousness?
    • Raised ICP

Causes of acute headache in children:

  • Ice cream
  • Febrile illness
  • Migraine
  • Stress
  • Acute sinusitis
  • Meningitis/encephalitis
  • Subarachnoid/intracerebral haemorrhage
  • Medications
  • Benign intractranial hypertension
  • Reflex neuralgia

Types of headache:

  • Tension
  • Migraine
    • with aura
    • without aura
    • complicated
  • Space occupying lesion
  • Other
    • sinusitis
    • TMJ discomfort
    • Medication
    • Refractive error
    • Solvent/drug abuse
    • Benign intracranial hypertension
    • Hypertensive headache

can we stop now?

Headache differential

“Doctor I have a headache – am I going to die?”


“Well… eventually…”

As a doctor you have to try and give useful answers to fairly important questions, like, better than this.

 

Differential diagnoses are one of the most useful tools when it comes to diagnosing symptoms and it’s important to ensure you’ve thought of as many of the potential causes as possible. Here’s a weird way to remember the key causes of a headache in an emergency situation.

Typical Day in A&E

You are on duty in the emergency department and you’re feeling incredibly tense, as someone has just fired off a cluster grenade somewhere in the hospital. You’ve just been called in to see a patient who has a very bad headache, who says he has a history of migraines


As you enter the room, you notice he’s holding a cricket bat and smoking a huge joint. Next to him a washing machine is spinning out of control, pouring smoke all over the room.


You notice a weird tingling stiffness in your neck, when suddenly his head catches fire.


The man stands up and says “To Be Honest mate I’m just gonna go home”, but his head begins to expand and he starts grinding his jaw


You don’t see what happens next because you go blind and pass out.

  • Tension headache
  • Cluster headache
  • Migraine
  • Subarachnoid (feels like being hit with a bat)
  • Drugs
  • CO poisoning 
  • Meningitis
  • Encephalitis
  • TBH – Tumour, TB, Haematoma
  • Temporal arteritis
  • Glaucoma

Step 1: Take a history


RED FLAGS:

  • First and worst headache ever
  • Sudden onset and really bad
  • Unilateral with eye pain
  • Worse on coughing
  • Scalp tenderness
  • Decrease in GCS

– Any trauma?

– Any neck pain?

– Any fever?

– Any loss of consciousness?

– Any decrease in consciousness?

– Any warning signs?

– Any fitting/biting of tongue?

– Any other medical conditions?

– Any changes in vision?

– Any drugs?

– Sudden or gradual onset?

– How severe?

Two crucial questions:

– “Have you been away?”

– “Could you be pregnant?”

Step 2: Do a neuro exam

Step 3: Look in their eyes

Step 4: Get thinking

DDx:

No signs on examination:

Tension headache

– Migraine

– Cluster

– Post-trauma

– Drugs – particularly nitrates and calcium channel blockers

– CO poisoning


Signs of meningism:

– Meningitis

– Subarachnoid haemorrhage


Decreased consciousness:

– Encephalitis

– Meningitis

– Stroke

– Cerebral abscess

– Subarachnoid haemorrage

– Tumour

– Haematoma

– TB meningitis


Papilloedema:

– Tumour

– Malignant hypertension

– Benign intracranial hypertension

– CNS infection of >2weeks


Painful jaw/temple:

– Temporal arteritis


Changes in vision:

– Glaucoma


Other:

– Paget’s disease

– Sinusitis

– Altitude sickness

– Cervical spondylosis

– Venous sinus occlusion

– Vertebral artery dissection

All of the above information is from the Oxford Handbook of Clinical Medicine 7th Edition