Assessment of acute headache in children

positive family history of migraine; symptoms may be unilateral or pulsing; pain moderate or severe, aggravated by physical activity; may be associated with nausea, vomiting, photophobia, or phonophobia; may occur with an aura[20]National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Dec 2021 [internet publication]. https://www.nice.org.uk/guidance/cg150

normal

frontal headache; purulent nasal discharge; facial pain and congestion; fever, cough, headache, fatigue, dental pain, ear pain or fullness

nasal obstruction, halitosis, facial tenderness

rapid onset of severe headache often described as 'worst headache of my life'

may be associated with altered consciousness, meningeal signs, or focal signs; may be no physical findings

acute onset of headache; focal seizures; symptoms of elevated intracranial pressure (headache, vomiting, depressed consciousness)

focal neurological signs, focal seizures, altered consciousness

abrupt onset of headache (thunderclap headache), altered mental status (suggestive of elevated intracranial pressure), may be history of trauma, may be related to vascular malformations (AVM), may be history of hypertension

altered mental status may suggest diffuse cerebral involvement or haemorrhage within the reticular activating system, or may suggest elevated intracranial pressure; focal neurological signs relate to the location of the haemorrhage

may be history of head or neck injury, the injury may be mild or considered insignificant, and the onset of symptoms may be delayed; presents with headache and neck pain, with or without focal neurological symptoms due to secondary stroke or transient ischaemic attack

focal neurological signs are consistent with a secondary stroke (hemiplegia with carotid dissections and hemiataxia with vertebral artery dissections); neck auscultation may reveal bruits; Horner's syndrome (mild ptosis, anhidrosis, and miosis) is consistent with carotid injury

gradual onset of headache made worse by bending over or squatting, or while straining with bowel movements (Valsalva); vision changes common (e.g., blurring, horizontal double vision, peripheral vision constriction, and transient visual obscurations); pulsatile tinnitus possible; fever may be present

meningismus and/or mastoid tenderness or swelling; focal or non-focal neurological findings; optic nerve oedema; bilateral ocular abduction limitation

history of trauma; confusion; altered concentration, memory, and problem solving; irritability; emotional changes; headaches may take several months to resolve

non-focal findings, except for mild alterations in mental status

history of trauma; confusion or personality change; focal seizures; headaches may recur with exertion weeks after the inciting event

focal neurological findings, altered level of consciousness, or abnormal mental status testing

usually occurs after head trauma; may be lucid intervals between the trauma and the onset of symptoms, which may develop quite slowly (because often due to a venous bleed) and include headache, seizures, and symptoms related to elevated intracranial pressure (vomiting and nausea)

focal findings on examination, focal seizures, altered level of consciousness, or coma

headache is generally diffuse and dull, worsens within 15 minutes of standing, and is associated with neck stiffness, tinnitus, hyperacusia, photophobia, and nausea; may be history of recent lumbar puncture or back/neck trauma; may be associated with Marfan's Syndrome, Ehlers-Danlos syndrome, neurofibromatosis, or polycystic kidney disease

abnormal hearing and photophobia; downward traction may lead to cranial nerve palsies or altered mental status, and may result in subdural hygromas or haematomas

usually history of head trauma; often a lucid interval between the trauma and the onset of headache; symptoms related to elevated intracranial pressure (vomiting and nausea); seizures

focal neurological findings, focal seizures, altered level of consciousness, or coma

acute onset of headache, fever, neck stiffness

positive meningeal signs (Kernig's and Brudzinski's signs), altered mental status

seizures; fever; exposure to infectious agent (e.g., arthropod-borne arboviruses such as eastern equine, western equine, St. Louis, Venezuelan equine encephalitis, and West Nile virus; herpes simplex type 1; lymphocytic choriomeningitis virus)

altered mental status ranging from minor deficits to complete unresponsiveness; focal motor or sensory neurological abnormalities; speech disorders; exaggerated deep tendon and/or pathological reflexes

pain typically localised to the mouth; may present as facial pain or headache

caries, gingival disease, abscess

indolent progressive headache, nausea or vomiting, difficult walking, visual symptoms, focal weakness, or personality change

optic nerve oedema, cranial nerve abnormalities, ataxia, abnormal reflexes, visual field or acuity defects

temporomandibular joint pain, noise in the joint (clicking, popping, or crepitus with/without locking), masticatory muscle tenderness, limited mandibular movement;, headache in the temporal region, otalgia and/or tinnitus without a significant ear disorder​​; associated symptoms, such as myalgia and arthralgia, depression and anxiety may be present

pain may be triggered by jaw movement or pressure on the masticatory muscles, and may be associated with jaw click or reduced jaw movement; maximal mandibular opening is 35-55 mm, movement may be reduced to <35 mm; there may be an uncorrected deviation on maximum mouth opening; wear facets are indicative of bruxism

often milder headache that is diffuse or posterior in location;[20]National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Dec 2021 [internet publication]. https://www.nice.org.uk/guidance/cg150 no associated migrainous features (nausea, vomiting, photophobia, phonophobia) or autonomic features

neurological examination is non-focal; trigger points may be identified in the neck

unilateral, severe, boring headache lasting 20 minutes occurring 10 to 40 times per day with autonomic symptoms such as nasal congestion, lacrimation, and conjunctival injection; or unilateral headache lasting hours or days associated with milder autonomic or migrainous symptoms

non-focal neurological examination

drug history of ergotamine, triptans, analgesics, opioids, or a combination of these medications; headache has developed or markedly worsened during overuse; headache resolves or reverts to prior pattern within 2 months of discontinuation of overused medication

neurological examination is non-focal

stabbing excruciating headache, often at the orbit, that lasts 15 to 180 minutes and occurs 1 to 10 times per day, often daily for several days or weeks, then resolves for several weeks or months

neurological examination is non-focal; autonomic features are present, including lacrimation, conjunctival injection, nasal congestion, ptosis, and eyelid oedema

headache for more than 3 months that is unremitting and occurs daily from within 3 days of onset; mild to moderate intensity, bilateral in location, and not worsened by routine activity; may be migrainous features

neurological examination is non-focal

intermittent severe headache

signs related to elevated intracranial pressure such as optic nerve oedema, abducens nerve palsy, or altered mental status may be present, but may not be present if obstruction is brief

headache made worse by bending over or squatting, or while straining with bowel movements (Valsalva); vision changes common (e.g., blurring, horizontal double vision, peripheral vision constriction, and transient visual obscurations); pulsatile tinnitus possible

non-focal examination findings; optic nerve oedema, bilateral ocular abduction

headache worse when supine; horizontal diplopia; history of trauma near track

new focal neurological signs; Cushing's triad of hypertension, bradycardia, and irregular breathing pattern; pupillary asymmetry; elevated intracranial pressure (altered mental status, horizontal diplopia, optic nerve oedema); evidence of disruption or tunnel infection (tenderness or erythema over the track); tenderness to abdominal palpation; ascites; acute abdomen (distal aetiology)

headache that is often acute onset; visual impairment (often diplopia)

ophthalmoplegia, shock

acute or gradual onset of decreased alertness, vision changes (blurring or obscuration), and seizures

examination may be limited by mental status change; hypertension

posterior or calvarial headache, pain with neck/shoulder movement

tenderness over occipital condyles

sudden lancinating unilateral facial pain

normal examination