Pediatric Headache Red Flags

The Challenge of Pediatric Headaches

Pediatric headaches can feel like a diagnostic minefield for urgent care clinicians. From benign tension headaches and migraines to potentially life-threatening conditions like brain tumors or meningitis, the stakes are high. And in pediatrics, those stakes feel even higher—missing a red flag could have devastating consequences.

But fear not! With a systematic approach to history-taking and the physical exam, you can confidently evaluate pediatric headaches and make informed decisions about the next steps. Here’s how.

History Red Flags: When to Worry

A thorough history is your first and most critical tool in evaluating a pediatric headache. Here are some red flags that should prompt further investigation or referral:

1. Thunderclap Headache: A headache that reaches maximum intensity within one minute is alarming and suggests a potential intracranial hemorrhage or reversible cerebral vasoconstriction syndrome (RCVS).
2. Progressive Headache: If a child’s headache is getting progressively worse or changing in pattern, this may indicate a space-occupying lesion or increased intracranial pressure (ICP).
3. Positional Headaches: Headaches that worsen with lying down or standing up could be related to increased ICP, often caused by a mass effect or pseudotumor cerebri.
4. Morning Headaches with Vomiting: Headaches that are worst in the morning and accompanied by vomiting may suggest increased ICP, potentially from a brain tumor.
5. Headaches in Children Under 5 Years: While young children can experience migraines, any headache in this age group should be approached with caution due to their inability to articulate symptoms effectively.
6. Headaches Triggered by Valsalva Maneuver: These headaches, triggered by actions like coughing, sneezing, or straining, can also point to increased ICP.
7. Headaches Waking from Sleep: Frequent nighttime awakenings due to headaches can be a sign of serious pathology.

Physical Exam Red Flags: Signs Not to Miss

The physical exam is just as crucial as the history. Key findings that should alert you to the possibility of a secondary headache include:

1. Any Neurological Abnormality: This includes focal deficits, ataxia, or cranial nerve abnormalities. Any of these signs should prompt immediate imaging and referral to a higher level of care.
2. Papilledema: This indicates increased ICP and is a red flag for serious intracranial pathology. A thorough fundoscopic exam is essential, and familiarity with this skill can be lifesaving. Bonus points for using Ultrasound to identify papilledema (since I can’t use a fundoscope to save my life, this is my go-to).
3. Signs of Meningitis: Acute headache with fever, neck stiffness, photophobia, and positive Kernig or Brudzinski signs should immediately raise concerns for meningitis, warranting urgent imaging and possibly lumbar puncture.

When to Pursue Imaging

Imaging is often necessary when red flags are present. MRI is generally preferred over CT in children due to the absence of radiation and better visualization of posterior fossa lesions. However, sedation may be required for younger children. In most cases, we won’t have this ability at urgent care, and transfer to a facility where it can be done should be considered.

Top Red Flags Recap

1. Neurologic Exam Abnormalities: The most important red flag, even with a worrisome history, a normal neurologic exam is somewhat reassuring.
2. Morning Headaches with Vomiting: Suggestive of increased ICP.
3. Headaches with Valsalva Maneuver: Also a red flag for increased ICP.

Stay Vigilant

Pediatric headaches are common, but the potential for serious underlying conditions necessitates a careful and thorough evaluation. Stay vigilant, and remember that a thorough history and physical exam are your best tools in the urgent care setting!