Headaches- Common or Concerning?

Bloody CSF

In the ED we are trained to think of the big, bad diagnoses first… and there are several concerning potential options when we consider Headaches (HA).

  • HA is a common complaint that we see in children (~75% of children will have HAs by the time they are 15yrs).
  • It is a common complaint in the ED – one study showed ~1% of all Ped ED visits were for HA.

Needles in the Haystack of Headaches

While the DDX is wide, most often the etiology will be benign (viral illness, strep pharyngitis, sinusitis, and migraines)… but, remember you are there to look for an find those needles in the haystack of benign HA’s.

  • Meningitis
  • Tumors
  • AVMs
  • Subarachnoid Hemorrhage
  • VP shunt malfunction
  • Rocky Mountain Spotted Fever
  • Carbon Monoxide Poisoning
  • Postictal HA
  • Postconcussive HA
  • Pseudotumor (to name a few)

Concerning Characteristics

In children / adolescents with abrupt onset of severe HA special attention should be paid to the history and physical exam (as always – H+P is the foundation upon which you make your medical decisions):

  • History
    • Timing:
      • Chronic Non-Progressive – chronic daily headaches, analgesic abuse
      • Chronic Progressive (gradually increasing intracranial pressure) – space-occupying lesion, chronic meningitis, and pseudotumor cerebri
      • Acute-Recurrent pattern (episodes separated by symptom-free periods) – migraine, tension-type HA, cluster HA, neuralgias, and epileptic variants
      • Acute – highly suggestive of organic pathology
    • Occipital location and an inability to describe the quality of pain are concerning for serious underlying pathology.
    • HA worse with lying down or awakens the patient at nigh
    • HA worse after walking
  • Physical Exam
    • Become the Sherlock Holmes of medicine and look for that small detail that reveals the answer (emerging rash? Neck Pain? Papilledema?).
    • One ED study demonstrated that ALL patients with serious underlying pathology had objective neurologic abnormalities (which means we need to do a thorough neurologic exam!).
      • Papilledema (always document a fundoscopic exam on your HA patients).
      • Ataxia
      • Hemiparesi
      • Abnormal eye movement
      • Depressed Reflexes

And, naturally, sometimes your patient doesn’t quite “look right” and falls outside the standard patterns that you recognize as being benign. Many thanks to Drs. Montgomery and Miller for the case of the patient with severe headache and neck pain… who had CSF that looked like Kool-aid. The needle found? AVM with hemorrhage.


Lewis DW, Qureshi F. Acute Headache in Children and Adolescents Presenting to the Emergency Department. Headache, 2000; 40:200-203.

Burton LJ, Quinn B, Pratt-Cheney JL, Pourani M. Headache Etiology in a Pediatric Emergency Department. Pediatric Emergency Care, 1997; 13(1): 1-4.

The Childhood Brain Tumor Consortium. The epide- miology of headache among children with brain tumor. Headache in children with brain tumors. J Neu- rooncol. 1991;10:31-46.

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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