Evaluation of acute headache in children

Thunderclap headache

Thunderclap headache (or sudden severe headache onset) is uncommon. However, it is often associated with a serious underlying brain disorder that requires specific and urgent therapy.[8]Linn FH, Wijdicks EF. Causes and management of thunderclap headache: a comprehensive review. Neurologist. 2002 Sep;8(5):279-89. http://www.ncbi.nlm.nih.gov/pubmed/12803675?tool=bestpractice.com

Possible etiologies include:

• Subarachnoid hemorrhage

• Parenchymal hemorrhage

• Sinovenous thrombosis

• Arterial dissection

• Pituitary apoplexy

• Intracranial hypotension

• Intermittent hydrocephalus.

Initial management includes the following.

Noncontrast head computed tomography (CT)

• After a history and physical examination, diagnostic testing often begins with a noncontrast head CT on which acute bleeding will be hyperdense.[7]American College of Radiology. ACR Appropriateness Criteria®: headache-child. 2017 [internet publication]. https://acsearch.acr.org/docs/69439/Narrative http://www.ncbi.nlm.nih.gov/pubmed/29724429?tool=bestpractice.com

Lumbar puncture

• Neuroimaging may be indicated prior to lumbar puncture to rule out a large mass lesion and assess risk for herniation.

• If subarachnoid hemorrhage is strongly suspected (i.e., thunderclap headache with severe rapid onset), and the head CT is nondiagnostic, lumbar puncture should be performed. Examination of centrifuged supernatant CSF for xanthochromia (yellow coloration) is the most sensitive method for detecting subarachnoid hemorrhage and is best identified and quantified in the laboratory, rather than visually. Xanthochromia can persist up to several weeks following a subarachnoid hemorrhage. If this method is not available, sending tubes 1 and 4 for a cell count can also enable differentiation between true subarachnoid blood and blood from a traumatic tap.

• If intracranial hypertension is suspected (i.e., headache worse when lying down or headache on waking, tinnitus, optic nerve edema, horizontal diplopia) or hypotension is suspected (i.e., recent back or neck trauma, headache worse when upright) then a lumbar puncture with opening pressure in the relaxed lateral recumbent position is indicated.

Other imaging modalities include magnetic resonance imaging (MRI) without contrast, magnetic resonance angiography and CT angiography.[7]American College of Radiology. ACR Appropriateness Criteria®: headache-child. 2017 [internet publication]. https://acsearch.acr.org/docs/69439/Narrative http://www.ncbi.nlm.nih.gov/pubmed/29724429?tool=bestpractice.com [9]Dubosh NM, Bellolio MF, Rabinstein AA, et al. Sensitivity of early brain computed tomography to exclude aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Stroke. 2016 Mar;47(3):750-5. http://www.ncbi.nlm.nih.gov/pubmed/26797666?tool=bestpractice.com

These may be performed if the following are clinically suspected:

• Arterial dissection (i.e., recent neck injury, neck pain, focal neurologic signs)

• Sinovenous thrombosis (i.e., evidence of intracranial hypertension, obesity or recent weight gain, use of medications with hypercoagulable risk such as oral contraceptive pills, focal neurologic signs)

• Tumor (i.e., slowly worsening headache, optic nerve edema, focal neurologic signs)

• Subarachnoid or subdural hemorrhage (identify arteriovenous malformation or aneurysm; identify amount and severity of injured brain parenchyma).

Only after appropriate evaluation can more benign etiologies be considered, including first or severe migraine, tension headache, or cluster headache.

Treatment is directed at the underlying etiology. Nonspecific pain medications may be used symptomatically for headache relief as needed. Often neurosurgical consultation and intensive care admission are required.

Acute herniation

Patients with intracranial lesions causing intracranial hypertension may present initially with:

• Headache, usually positional (worse when lying down)

• Vomiting, may be projectile

• Diplopia

• Depressed level of consciousness

• Ophthalmoplegia or pupil asymmetry (optic nerve edema may be absent depending on acuity of presentation)

• Cushing triad: hypertension, bradycardia with or without apneustic breathing (breathing characterized by a prolonged inspiratory phase followed by expiration apnea, most often associated with head injury).

If a space-occupying lesion is present, urgent neurosurgical consultation is required. Maintaining a neutral neck position and elevated head of bed (at 20 to 30 degrees) may improve venous drainage. Initial management of critically elevated intracranial pressure includes intravenous hyperosmolar therapy (mannitol or sodium) and hyperventilation to achieve a pCO₂ of 35 mmHg. Further reduction in pCO₂ may be necessary to achieve rapid but temporary reductions in cerebral blood flow and thus intracranial pressure, but excessive or prolonged hyperventilation may compromise cerebral perfusion, resulting in further hypoxic ischemic injury.

Traumatic brain injury

A detailed history of the mechanism of injury and any associated symptoms is essential. Examination should include a full neurologic assessment and examination for injuries including signs of basal skull fracture. Noncontrast MRI is indicated.[7]American College of Radiology. ACR Appropriateness Criteria®: headache-child. 2017 [internet publication]. https://acsearch.acr.org/docs/69439/Narrative http://www.ncbi.nlm.nih.gov/pubmed/29724429?tool=bestpractice.com Head CT can be used if there are concerning symptoms and MRI is not possible.[7]American College of Radiology. ACR Appropriateness Criteria®: headache-child. 2017 [internet publication]. https://acsearch.acr.org/docs/69439/Narrative http://www.ncbi.nlm.nih.gov/pubmed/29724429?tool=bestpractice.com Immobilization and imaging of the cervical spine might also be needed.