Help for headaches: A strategy for your busy practice

November 1, 2005

A five-step approach helps you rule out pathologic headache and start effective management for benign primary headache-all during a typical office visit.

DR. FISHER is associate professor of neurology, pediatrics, neurosurgery, and human biology, Stanford University School of Medicine, and The Beirne Family Director of Neuro-Oncology, Lucile Packard Children's Hospital, Palo Alto, Calif.

Staff editors: KAREN BARDOSSI, Senior Editor, and JOHN BARANOWSKI, Editor, Contemporary Pediatrics

The author, manuscript reviewers, and staff editors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

Although this scenario can trigger angst, approach the child calmly and systematically. After all, more than 75% of children complain of headache at least once by 15 years of age.1 You should be comfortable methodically following five steps to evaluate and manage a child with headache:

Using this approach, you should be able to address the 11-year-old patient's headaches successfully in about those 15 minutes and move confidently to the next patient.

Step 1 Exclude ominous headache

The first step in evaluating headache is to distinguish between primary, benign headache-that is, migraine-and secondary, pathologic headache. The latter stems from a structural lesion, such as a brain tumor, or other underlying condition, such as meningitis, hypertension, or intoxication. As with any other childhood illness, a thorough history from both parent and child is essential. Carefully elucidate the characteristics of the pain, using the alphabet mnemonic OPQRST as a guide:

Onset
Provocative and Palliative factors
Quality
Radiation to other regions
Severity
Temporal pattern

A thorough physical examination should follow, with particular attention to vital signs, especially blood pressure; occipitofrontal circumference; the Kernig and Brudzinski meningeal signs; and a limited neurologic exam to assess basic cranial nerve and motor function. Macrocephaly in an infant, or even an older child, can indicate subacute or chronic increase in intracranial pressure.

Children with craniopharyngioma are a rare exception to this rule because the tumor may irritate the underlying dura and cause headache while the mass is still small and not causing neurologic signs. Nevertheless, children with this uncommon tumor almost always have other signs in addition to the headache, specifically short stature, visual loss, and endocrinopathy.4