Differentials
Cluster headache
SIGNS / SYMPTOMS
Usually severe in nature; unilateral; orbital, supra-orbital, and/or temporal; and lasts from 15 to 180 minutes.
Conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, and eyelid oedema on the side of the headache are all commonly associated symptoms.
INVESTIGATIONS
The diagnosis is clinical and there is no specific investigation that will distinguish cluster headache from migraine.
Tension headache
SIGNS / SYMPTOMS
Episodic tension-type headaches are usually bilateral, last from 30 minutes to 7 days, have a pressing or tightening quality, and are not aggravated by physical activity.
Nausea, vomiting, photophobia, and phonophobia are not typical accompaniments.
INVESTIGATIONS
The diagnosis is clinical and there is no specific investigation that will distinguish tension headache from migraine.
Post-traumatic headache
SIGNS / SYMPTOMS
Headaches following a well-defined concussive head injury are not unusual, and are likely to remit over a period of a few days or some weeks.
There should have been a notable injury that predated the onset of headaches.
A small traumatic extradural haematoma may manifest as persisting headache and vomiting post-injury without other clinical signs.
The presence of hypertension, bradycardia, altered consciousness level, or any focal neurological deficit suggests a more serious injury or alternative diagnosis and is an indication for urgent central nervous system imaging.[21]
INVESTIGATIONS
CT brain: in the absence of a focal neurological deficit, hypertension, bradycardia, or altered consciousness level, CT is likely to be normal.
Dental abscess
SIGNS / SYMPTOMS
Presence of fever is a clear indicator that migraine is not a tenable diagnosis.
Toothache.
History of dental caries.
INVESTIGATIONS
FBC may demonstrate elevated WBC count, and blood cultures may be positive.
Otitis media
SIGNS / SYMPTOMS
Presence of fever is a clear indicator that migraine is not a tenable diagnosis.
Earache.
INVESTIGATIONS
FBC may demonstrate elevated WBC count, and blood cultures may be positive.
Meningitis
SIGNS / SYMPTOMS
Presence of fever is a clear indicator that migraine is not a tenable diagnosis.
Meningism is present.
INVESTIGATIONS
Cerebrospinal fluid cultures may be positive in suspected meningitis.
Sinusitis
SIGNS / SYMPTOMS
Presence of fever is a clear indicator that migraine is not a tenable diagnosis.
Face pain and nasal discharge.
INVESTIGATIONS
FBC may demonstrate elevated WBC count, and blood cultures may be positive.
Central nervous system (CNS) pathology
SIGNS / SYMPTOMS
Less than 1% of children with headache have a brain tumour. Nocturnal or early-morning headaches may be indicative of elevated intracranial pressure secondary to a space-occupying lesion such as a tumour.
Altered consciousness level, seizures, inappropriate behaviour (especially if recent onset), increasing head circumference, 'sun-setting eyes', prominent scalp veins, papilloedema, ophthalmoplegia, HTN with or without bradycardia, cranial nerve palsies, motor deficits, and cerebellar signs all suggest a more sinister CNS disorder: for example, tumour,[22] encephalitis, encephalomyelitis, vasculitis/malformation, venous sinus thrombosis, and degenerative disorder.
INVESTIGATIONS
In children <4 years of age with headaches, neuroimaging should be given strong consideration to exclude a space-occupying lesion.
CT/MRI brain and lumbar puncture are normal in migraine and (when indicated) will usually confirm the presence of an alternative pathology.
Refraction error
SIGNS / SYMPTOMS
If old enough, the child may give a history suggestive of myopia or hypermetropia.
INVESTIGATIONS
Formal assessment of visual acuity confirms the diagnosis of a refraction error as the cause of headaches.
Hypertension
SIGNS / SYMPTOMS
Measurement of BP is mandatory in all children with headaches.
INVESTIGATIONS
In a child with headaches, the presence of hypertension should precipitate a comprehensive search for a cause that is usually renal, vascular, endocrine, or neurological in origin.
Headache of low intracranial pressure
SIGNS / SYMPTOMS
History of a recent lumbar puncture or dural tear.
Lying down often relieves low-pressure headaches to some degree.
INVESTIGATIONS
Diagnosis is clinical.
Toxin-related headache
SIGNS / SYMPTOMS
Substance abuse (e.g., cocaine, marijuana) or poisoning (e.g., carbon monoxide) are elicited in the history.
These should be considered when symptoms are atypical and age/social circumstances might suggest that toxin exposure is a theoretical possibility.
INVESTIGATIONS
Urinalysis will demonstrate the presence of a toxin such as cocaine.
Specific site testing is indicated when carbon monoxide poisoning is considered a possibility.
Temporomandibular joint dysfunction
SIGNS / SYMPTOMS
Clinical examination (palpation, movement) should suffice in confirming or excluding the temporomandibular joint as a source of pain.
INVESTIGATIONS
Diagnosis is clinical.
Obstructive sleep apnoea
SIGNS / SYMPTOMS
This may manifest as early-morning headaches, with accompanying nausea and anorexia, in a child who snores at night with nocturnal arousals and daytime somnolence.
INVESTIGATIONS
Diagnosis is clinical.
Analgesic headache
SIGNS / SYMPTOMS
Teenagers are at greatest risk.
Analgesic use on a daily or near-daily basis should prompt the clinician to consider this diagnosis.
INVESTIGATIONS
Diagnosis is clinical.
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