Headaches in Children: History Taking and Differential Diagnoses

Overview

The most common headaches in children are migraine without aura and tension-type headaches. Headaches can be classed as primary (the headache on its own) or secondary (the headache is a symptom of an underlying disorder). To diagnose a primary headache, secondary causes must be excluded.

Causes

• Primary headaches:
  • Migraine – most common
  • Tension-type headache – second most common
  • Medication-overuse headache
  • Cluster headache
  • Paroxysmal hemicrania
• Secondary headaches – less common, but may be severe:
  • Trauma and intracranial haemorrhage
  • Meningitis
  • Encephalitis
  • Sinusitis
  • Otitis media
  • Brain tumours
  • Idiopathic intracranial hypertension
  • Hydrocephalus

History Taking

History of presenting complaint

With each symptom, always (if relevant) ask about:

• When did it start?
• Did it come on suddenly or gradually?
• Is it continuous or intermittent?
• Has this ever happened before?

Paediatric systems review

Briefly screen for the following, and adjust where appropriate:

• Screening for general features:
  • Fever, chills, rigours, sweating
  • Crying – is it consolable or inconsolable?
  • Growth, weight loss 
  • Behaviour, appetite, alertness, activity, sleeping
• Screening for cardiorespiratory features:
  • Cough, shortness of breath
  • Noisy breathing (stridor, wheezing), rapid breathing
  • Cyanosis
• Screening for gastrointestinal features:
  • Vomiting, diarrhoea, constipation, stool character (e.g. mucus, blood, melaena etc.)
    • Bloody diarrhoea is generally rare in children and may be due to infection or inflammatory bowel disease
  • Abdominal pain, abdominal distension
• Screening for genitourinary features:
  • Urine output and hydration – number of wet nappies, number of times using the toilet
  • Dysuria, frequency, urgency, enuresis, loin pain
  • Haematuria
  • Scrotal swelling
• Screening for neurological features:
  • Headaches, neck stiffness, photophobia
  • Level of consciousness
  • Seizures, fits, falls, or ‘funny turns’
  • Changes in gait, abnormal movements
  • Vision changes, hearing changes
  • Hypotonia (floppiness), hypertonia (stiffness, spasticity)
• Screening for ear, nose, and throat features:
  • Ear: pain, discharge, hearing changes
  • Nose: epistaxis, discharge, congestion
  • Throat, mouth, and neck: sore throat, neck swelling, limited neck movement, mouth ulcers
• Screening for haematological features:
  • Bleeding, bruising, gum bleeding, fatigue, pallor 
• Screening for skin features:
  • Rash, itching, crusting, oozing, changes in skin pigmentation
• Screening for musculoskeletal features:
  • Limp, limitation in movement
  • Joint pain, joint swelling, joint stiffness

Birth

• How was the pregnancy?
  • Any abnormal scan results or extra scans? Why?
  • Any problems? – including maternal illness, diabetes, alcohol, drinking, drug use
• What happened during birth?
  • Number of weeks gestation?
  • Weight at birth?
  • Birth location? – such as in hospital, at home?
  • Mode of delivery? – vaginal delivery, caesarean section?
  • Any complications to both the mother or child during or after birth?
  • Did they need to stay in hospital for longer/was there any admission to neonatal intensive care?

Feeding and toileting

• Ask about diet and appetite:
  • What is their diet and appetite usually like and what is it like now?
  • Breastfed or formula milk?
  • When and how did weaning start?
• Ask about toileting:
  • Are they toilet trained?
  • How often do they go to the toilet/how many wet nappies?

Growth

• How is their weight?
  • Are they gaining weight, staying the same, or struggling to gain weight?
  • Do they have their personal child health record (PCHR, the ‘red book’)
• Have they started puberty?
  • Usually 8-13 for girls, 9-14 for boys 

Development

• Is the child meeting developmental milestones?
• Are there any concerns with development?
• How is school/nursery progress and attendance?
• Perform a developmental assessment if necessary

Immunisations

• Are they up to date with their immunisations?

General questions

• Do they have any other medical conditions?
• Have they ever had any previous surgery?
• Do they take any regular medications?
• Do they take any over-the-counter medications, herbal remedies, or supplements?

Family history

• Is there any family history of anything similar?
• In some autosomal recessive inherited diseases, consanguinity may be possible, ask about this sensitively if necessary

Allergy history

• Are they allergic to anything?
  • What happens during the allergic reaction?

Social history

• Ask about their home situation:
  • Who’s at home?
    • Ask about parents/carers, siblings, other people at home
  • What support does the child and parent/carer have?
  • What is their housing situation? – e.g. cramped housing
  • What are the parent’s occupations?
  • How is the parents’/carers’ mental health?
• Ask about the child’s activities including school and nursery:
  • Does the child go to school/nursery?
  • Has the child had to stay home from school/nursery?
• Ask about smoking, drinking, and illicit drug use sensitively:
  • Does anyone smoke inside or outside of the house?
  • Does anyone drink alcohol inside the house?
    • If relevant, does the young person drink alcohol?
  • Does anyone at home use illicit drugs?
    • If relevant, does the young person use illicit drugs?
• Ask questions regarding safeguarding:
  • Are they known to social services?
  • Are there any safeguarding concerns?
  • You may need to separately ask the child about safeguarding concerns including:
    • Are they at risk of harm?
    • Are they being made to do things they don’t want to do?
• Ask about possible infectious contacts:
  • Is anyone else at home ill?
  • Has anyone in school/nursery been ill?
  • Has there been any recent foreign travel?

Differential Diagnoses

Migraine

• A history may reveal:
  • POUNDing: pulsatile, 4-72 hOurs, Nausea +/- vomiting, Disabling intensity (cannot continue normal activity)
  • There may be associated photophobia and phonophobia
• Diagnosis is clinical

Tension-type headache

• A history may reveal:
  • Pain is described as a tight band around the head, not pulsatile, pain not severe 
  • No associated photophobia, phonophobia, nausea, or vomiting
• Diagnosis is clinical

Medication-overuse headache

• A history may reveal:
  • Pain occurring >15 days in a person with overuse of analgesia
  • Headaches worsen when attempting to stop analgesia
  • The new headache is different to the current type they have
  • Headache usually resolves within 2 months of stopping the overused medication
• Diagnosis is clinical

Cluster headache

• A history may reveal:
  • Severe unilateral orbital or temporal pain lasting 15 minutes to 3 hours
  • Eye redness, lacrimation, nasal congestion, facial swelling
  • Attacks occur in clusters lasting weeks to months with periods of remission
• Patient may smoke and/or drink alcohol
  • A physical exam may reveal:
  • Agitation, eye redness, lacrimation, ptosis, miosis, runny nose, facial swelling
• Diagnosis is clinical

Paroxysmal hemicrania

• A history may reveal features similar to a cluster headache
  • Severe unilateral orbital or temporal pain lasting 15 minutes to 3 hours
  • Eye redness, lacrimation, nasal congestion, facial swelling
  • Attacks occur in clusters lasting weeks to months with periods of remission
  • Patients may smoke and/or drink alcohol
• Symptoms resolve with indomethacin

Subarachnoid haemorrhage

• A history may reveal:
  • Sudden severe ‘thunderclap’ headache, may have similar ‘sentinel’ headaches preceding current headache
  • Pain usually reaches maximal intensity within 15- minutes
  • Photophobia and neck stiffness may be present
• A physical exam may reveal neck stiffness
• Investigations may reveal:
  • CT head without contrast:
    • Identifies subarachnoid haemorrhage

Meningitis

• A history may reveal:
  • Features may be non-specific: fever, headaches, muscle aches, joint pain, nausea and/or vomiting, refusing food and drink, lethargy, ill appearance, shortness of breath
  • Neck stiffness, headaches, nausea, vomiting, photophobia, skin rashes
  • Non-blanching rash may be present in meningococcal septicaemia 
• A physical exam may reveal:
  • Brudzinski’s sign, Kernig’s sign
• Investigations may reveal:
  • Blood culture – identifies underlying organism
  • Lumbar puncture and CSF analysis (if not contraindicated) – identifies underlying organism

Encephalitis

• Seizures, fever, altered mental status, nausea, vomiting
• Focal neurological deficits including speech aphasia may be present
• Investigations may reveal:
  • Lumbar puncture (if not contraindicated):
    • May show elevated protein, lymphocytosis and polymerase chain reaction may identify underlying agent
  • CT/MRI brain:
    • To screen for haemorrhage/herniation, may show petechial haemorrhages
  • Electroencephalogram:
    • May show generalised slowing or wave disorganisation

Acute sinusitis

• A history may reveal:
  • Nasal congestion, nasal discharge, post-nasal drip, fever
  • Frontal headache that is worse when bending forwards
  • There may be ear pain or fullness and dental pain
• A physical exam may reveal:
  • Reproducible sinus tenderness when palpating the frontal and maxillary sinuses
• Diagnosis is clinical

Brain tumours

• A history may reveal:
  • Headaches that vary with posture (e.g. coughing, sneezing, straining, leaning forward), nocturnal headaches that prevent sleep or wake the patient up, headaches that are present upon waking
  • Personality changes may be present
  • Focal neurological deficits, unexplained weight loss
• A physical exam may reveal:
  • Focal neurological deficits including visual field defects, cranial nerve abnormalities may be present
• Investigations may reveal:
  • CT brain – may show lesions with or without surrounding oedema
  • MRI brain with/without contrast – may show lesion

Idiopathic intracranial hypertension

• A history may reveal:
  • Generally an overweight person of female sex 
  • May be taking the combined oral contraceptive pill, corticosteroids, or tetracycline antibiotics
  • Blurred vision, nausea, headache may vary with posture (e.g. coughing, sneezing, leaning forward), headache may be worse in the morning
  • There may be pulsatile tinnitus
• A physical exam may reveal:
  • Papilloedema, enlarged blind spot, CN VI palsy may be seen
• Investigations may reveal:
  • CT brain – to screen for masses or structural problems
  • MRI brain – to screen for masses or structural problems
  • Lumbar puncture – increased opening pressure

Hydrocephalus

• A history may reveal – usually seen neonates:
  • Irritability, vomiting, seizures, reduced consciousness
• A physical examination may reveal:
  • Bulging anterior fontanelle, increasing head circumference, ‘sunset eyes’ (eyes are in a downward gaze with the lower half of the eye covered by the lower eyelid. The upper eyelids are retracted and the sclerae are visible above the iris)
• Investigations include:
  • CT head:
    • Used first-line and identifies ventricular dilation
  • MRI head:
    • Used to assess hydrocephalus in more detail and identify possible structural abnormalities
  • Lumbar puncture – avoid in obstructive hydrocephalus:
    • Is both diagnostic and therapeutic as it allows measurement of CSF pressure and drains CSF
    • Lumbar punctures should be avoided in obstructive hydrocephalus as reduced spinal CSF pressure compared to the brain CSF pressure causes the contents within the meninges to move downwards causing brain herniation

Carbon monoxide poisoning

• A history may reveal:
  • Classically questions may hint at badly maintained housing (e.g. poor boiler function or furnaces)
  • Other household members may have similar symptoms
  • Pets may be unwell
  • Headaches are an early feature, nausea, vomiting, confusion, and weakness follow
• A physical exam may reveal:
  • Tachypnoea, poor coordination, reduced consciousness
• Investigations may reveal:
  • Oxygen saturation – may be normal
  • Arterial blood gases – carboxyhaemoglobin:
    • 3% or more in people who do not smoke

10% in people who smoke