Acute headache in children and adolescents presenting to the emergency department

Our goals were (1) to investigate the causes of acute headache in childhood from the emergency department perspective and (2) to search for clinical clues that might distinguish headache associated with serious underlying disease.

The clinical presentation of headache in children and adolescents can be separated into 5 temporal patterns: acute, acute-recurrent, chronic progressive, chronic nonprogressive, and mixed. Few data exist regarding acute headache in children.

Consecutive children who presented to our emergency department with the abrupt onset of severe headache were prospectively evaluated. The headache character, location, severity, and associated symptoms, as well as underlying causes, were recorded using a standardized survey.

One hundred fifty children, aged from 2 to 18 years, 87 boys and 63 girls, were enrolled over a 10-month period. Upper respiratory tract infection with fever (viral upper respiratory tract infection 39%, sinusitis 9%, streptococcal pharyngitis 9%) was the most frequently identified cause of acute headache (57%). Other causes included migraine (18%), viral meningitis (9%), posterior fossa tumors (2.6%), ventriculoperitoneal shunt malfunction (2%), epileptic seizure (postictal headache) (1.3%), concussion (postconcussive headache) (1. 3%), intracranial hemorrhage (1.3%), and undetermined (7%). Two clinical features were found to have statistically significant associations with serious underlying disease: occipital location of headache and an inability of the patient to describe the quality of the head pain. All children with surgically remediable conditions had clear and objective neurological signs.

In children and adolescents, the abrupt onset of severe headache is most frequently caused by upper respiratory tract infection with fever, sinusitis, or migraine. Special attention is warranted if the acute headache is occipital in location and if the affected patient is unable to describe the quality of the pain. Serious underlying processes such as brain tumor or intracranial hemorrhage are uncommon and, when present, are accompanied by multiple neurological signs (ataxia, hemiparesis, papilledema).