A 13-year-old female came to clinic with a 2 day history of fever to 101.2°F, cough, runny nose, muscle pain in her legs and headache. The leg and headache pain were what she complained about most. Overall she had been drinking and urinating but had eaten little. She was using acetaminophen with some relief. The leg pain came and went, and was not increasing. She said she had normal strength and denied arthralgias. She had no arm or back pain. Her headache was band-like around the frontal/occipital area and constant. It was rated at a 4-5 overall at the worst when she was running a fever, but improved to a 1-2 when she was afebrile. She denied any visual or hearing changes, and no changes in the head with different position or Valsalva. None of her symptoms were significantly progressing. She was un-immunized for influenza and COVID. The past medical history was positive for intermittent migraine with aura since her onset of menses at 11 years of age. This was similar to her mother and aunt’s onset of migraine headache. She said this headache was different than her migraine headache.
The pertinent physical exam had normal vital signs and growth was tracking at the 50-75%. HEENT showed increased tearing and rhinorrhea. Her eye examination was PERRLA, with normal extra ocular movements and normal fundoscopic examination. Her pharynx and ears were normal, as were her heart, lungs and abdomen. Her skin and neurological examination were also normal.
The diagnosis of a viral syndrome was made with suspected influenza confirmed by rapid testing. Symptomatic instructions were given and antiviral medication was not offered as the patient did not qualify to use it.
Discussion
Headache (HA) is a very common problem. Almost everyone at some point will have a self-limited illness, minor trauma, or even just overworked muscles that can cause a headache. Median age of HA onset is 7.5 years. By age 15 it is estimated that 57-82% of patients will have HAs. Migraine prevalence is estimated to be 25-30% in 15-25 year olds. Boys are more affected in the school age years, and after puberty girls predominate. A primary headache problem (especially migraine with aura) or a self-limited illness are the most common reasons for HAs.
History and physical examination are the keys to identifying and managing treatment and expectations. History should include:
- Onset and duration
- Temporal pattern – first HA, recurrent but normal in between, frequent but non-worsening HA, worsening HA
- Location
- Quality – squeezing, throbbing, pounding, stabbing, band-like
- Associated problems – nausea, emesis, aura (especially photophobia or phonophobia), dizziness, weakness, diplopia
- Any warning that HA is starting
- HA has awoken patient at night or occurs first thing in the morning
- History of seizures
- Activities, foods or medicine that affect HA
Physical examination should include vital signs including temperature and blood pressure, careful ocular examination of pupillary responses and movement along with fundoscopic evaluation for possible optic nerve edema. Visual fields may be attempted to be assessed. Signs of systemic illness include sinus tenderness, muscle tightness/trigger points. Neurological examination for facial symmetry, nuchal rigidity, motor strength, reflexes, gait, balance, and coordination are recommended to be evaluated. The skin may show neurocutaneous abnormalities.
Red flag signs and symptoms for a secondary HA cause include:
- Acute severe HA
- Abnormal neurological or visual examination
- Mental status changes – confusion, mood, school performance changes
- Emesis
- Systemic illness symptoms
- Comorbid seizures
- Progressive worsening of HA history
- Positional HA
- Worsening HA in the morning or with l maneuver
- No visual aura
- Lack of family history of migraine
- Duration < 6 months
- Child age < 3 years
Patients generally do not need laboratory or electroencephalograms for recurrent HA. Red flag symptoms, traumatic brain injury, symptoms of hydrocephalus, and suspected intracranial infection are common reasons for neuroimaging. Lumbar puncture is sometimes used after imaging. Neurology consultation is considered “…typically at the point of considering a daily preventative agent or if an acute abortive agent or “cocktail is ineffective….”
Learning Point
The differential diagnosis for HA includes:
- Primary HA
- Usually are chronic (< 6 months), are daily or recurrent, occur anytime of day, lasting hours to days, located in frontal or temporal area and are described as squeezing or throbbing, often with visual or phonological aura, and associated with more nausea than emesis.
- Migraine
- Very common in children and teenagers, often with some type of aura, moderate to severe throbbing/pulsating quality that is often unilateral but can be bilateral, frontal/facial location. Migraine with aura is the most common primary headache with overall prevalence of 9.1%.
- With aura
- Without aura
- Periodic syndromes
- Cyclic vomiting
- Abdominal migraine
- Benign positional vertigo of childhood
- Chronic migraine
- Tension
- Occurs usually on 1 day/month on average and patient is well between episodes. Bilateral or band location with pressure or squeezing pain. No aura, nausea or emesis. Last 30 min to 7 days
- Chronic daily HA
- Usually combination of migraine and tension HA
- Trigeminal autonomic cephalgias including cluster HA
- Often in males, often episodic or chronic lasting 15-180 minutes, often severe unilateral orbital, suborbital or temporal pain, has autonomic symptoms such as lacrimation, rhinorrhea, facial swelling or sweating.
- Usually are chronic (< 6 months), are daily or recurrent, occur anytime of day, lasting hours to days, located in frontal or temporal area and are described as squeezing or throbbing, often with visual or phonological aura, and associated with more nausea than emesis.
- Secondary HA
- Usually are acute or subacute, are progressive and constant, occur more in morning or after awakening, located posteriorly and described as pressure, may have diplopia and more emesis than nausea.
Patients with brain tumors often will worsen over several weeks and it is uncommon for symptoms to persist > 6 months without neurological abnormalities.
- Trauma
- Vascular
- Subarachnoid hemorrhage
- Subdural hematoma
- Cervical artery dissection
- Venous sinus thrombosis
- Reversible cerebral vasoconstrictive syndrome
- Intracranial hypertension
- Tumor
- Pseudotumor cerebri
- Hydrocephalus
- Infection
- Abscess
- Meningitis
- Head and neck infections
- Hypertension
- Medication/substance use/withdrawal
- Medication overuse HA especially where patients are using a variety of analgesics, triptans, ergots, etc. more than 10-15 days/month. Often worsens with withdrawal
- Psychiatric disorders
- Anxiety, depression, post-traumatic stress disorder, conduct disorder, etc.
- Post-Seizure
- Usually are acute or subacute, are progressive and constant, occur more in morning or after awakening, located posteriorly and described as pressure, may have diplopia and more emesis than nausea.
Patients with brain tumors often will worsen over several weeks and it is uncommon for symptoms to persist > 6 months without neurological abnormalities.
Questions for Further Discussion
1. What lifestyle changes do you recommend for patients with HA?
2. What medications are used to abort HA?
3. What medications are used to prevent HA?
Related Cases
- Symptom/Presentation: Cough | Headaches | Fever and Fever of Unknown Origin
- Specialty: General Pediatrics | Emergency Medicine |
Neurology / Neurosurgery
- Age: Teenager
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Headache, Influenza, and Migraine.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Kelly M, Strelzik J, Langdon R, DiSabella M. Pediatric headache: overview. Curr Opin Pediatr. 2018;30(6):748-754. doi:10.1097/MOP.0000000000000688
Klein J, Koch T. Headache in Children. Pediatr Rev. 2020;41(4):159-171. doi:10.1542/pir.2017-0012
Merison K, Victorio MCC. Approach to the Diagnosis of Pediatric Headache. Semin Pediatr Neurol. 2021;40:100920. doi:10.1016/j.spen.2021.100920
Patel VA, Liaw J, Saadi RA, Isildak H, Kalmar CL, Polster SP. Headache Diagnosis in Children and Adolescents. Otolaryngol Clin North Am. 2022;55(3):633-647. doi:10.1016/j.otc.2022.02.007
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
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