1. History of Presenting Complaint

• from many sources including patient, parents, teachers, etc
• best to get a description of the initial and most recent headaches
• children over the age of 4 may give a good description
• onset
  • when began with conditions identified around initial headache, i.e., trauma, drug ingestion
• precipitation/palliation
  • identification of triggering agents
    • stressors (alterations in lifestyle, family tension), foods, medications
  • family history of headaches
  • techniques used to dissipate headache, i.e., sleep medications
• quality
  • sharp, dull, tight
  • throbbing or pounding (vascular)
  • is the character of the pain changing over time
• radiation
  • unilateral or bilateral headache
  • where does the headache start and hurt the most and does it spread to other areas
  • occipital - neck problems, occipital neuralgia, basilar migraine
  • facial - sinus, dental, or TMJ
• severity
  • on a scale of 1-10, 10 being the worst pain felt, how severe is the headache and is the pain increasing or decreasing in intensity over time
  • does headache interfere with child's day to day activities
  • migraines do not have to be severe
• timing
  • constant vs intermittent
  • duration and is duration increasing over time
    • in the absence of other symptoms, recurrent headaches of more than 3 months duration are rarely due to an organic etiology
    • headaches of duration less than 3 weeks are worrisome
  • frequency per day, week, month and is frequency increasing over time
  • time of day, week, month, season
• associated symptoms
  • functional inquiry
    • see Specific Entities below and files in the Database on the individual disorders listed in the differential diagnosis for headache - nausea/vomiting and/or abdominal pain (migraine)
    • photophobia, facial pain, fever
    • transient neurological signs
      • acute confusion, hemiplegia, opthalmoplegia, syncope, vertigo, paresthesias, phonophobia
    • aura
      • motor, sensory, visual
    • depression
      • anorexia, declining school performance, insomnia, weight loss
    • other medical problems
      • past medical history

2. Physical

1. Traction (Brain Tumors)

• headaches rapidly increase in frequency and severity
• worse upon awakening in the morning and improve during the course of the day; headache awakens from sleep - aggrevated by coughing or Valsalva manoeuvre
• may be relieved by vomiting
• associated symptoms
  • focal neurological findings, altered gait, changes in behaviour, personality, cognition, and/or learning
• 88% of children with a brain tumor will show abnormal neurologic signs within first 4 months of headache onset

2. Pseudotumor Cerebri

• headaches intermittent
• associated symptoms
  • blurred vision, diplopia, nausea & vomiting (N/V) papilledema

3. Classical Migraine

• headaches periodic and separated by symptom-free intervals and associated with at least 3 of the following:
  • abdominal pain, nausea/vomiting
  • aura (motor, sensory, visual)
  • family history
  • unilateral
  • sleep relief
  • pulsatile (throbbing)
• see "Migraine" file for description of other types of
• Migraines

4. Tension

• headache - bandlike tightness or pressure in the bifrontal, occipital, or posterior cervical regions lasting for days or weeks but not disrupting regular activities; not associated with a prodrome; seen at any age
• associated symptoms
  • tight neck muscles, sore scalp
  • nausea/vomiting and aura are uncommon

5. Refractive Error

• headache persistent and frontal which is worse during reading or doing school work

6. Temporomandibular Joint Dysfunction

• temporal headache
• associated symptoms
  • local jaw discomfort, malocclusion (crossbite), decreased range of motion of mouth and click with jaw movement, bruxism (grinding of teeth)

7. Chronic Sinusitis

• unusual for children less than 10 years of age to have recurrent headaches secondary to chronic sinusitis
• frontal headache
• tenderness to percussion over the frontal, maxillary, and/or nasal sinuses
• associated symptoms
  • prolonged rhinorrhea and congestion
  • chronic cough and postnasal drip
  • anorexia, low grade fever, malaise

1. Sinus X-Rays

• to rule out sinusitis

2. CT/MRI

• with contrast to rule out vascular malformations
• proposed indications for:
  • chronic progressive headache
  • complicated migraine
  • cranial bruit
  • migraine with focal seizure
  • persistent or localized neurologic findings
  • personality and/or behavioural changes
  • prolonged aura
  • severe recurrent unilateral headache

1. Relaxation-Imagery Therapy

• abdominal breathing exercises, visual imagery exercises

2. Biofeedback Therapy

• EMG and thermal biofeedback training to demonstrate vol-untary control over physiologic responses

1. Analgesics

• useful with tension headaches and mild migraines

2. Migraines

• see file on "Migraines"