Headache in children: Approach to evaluation

and general management strategies

Authors:
Daniel J Bonthius, MD, PhD
Andrew D Hershey, MD, PhD, FAAN, FAHS
Section Editors:
Jan E Drutz, MD
Marc C Patterson, MD, FRACP
Jerry W Swanson, MD, MHPE
Deputy Editor:
Mary M Torchia, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Sep 2022. | This topic last updated: Sep 19, 2022.

INTRODUCTION Headache (commonly defined as pain located

above the orbitomeatal line) is one of the most common complaints in children
and adolescents. It is recognized as one of the top medical and neurologic
contributors to the global burden of disease and is a leading cause of disability
in adolescents and young adults (age 10 to 24 years) [1,2].

The prevalence of headache increases with age. Children who complain of

headache usually are brought to medical attention by their caregivers due to
missing school or social activity or concerns of an ominous etiology such as a
brain tumor or other serious disease. The first steps in evaluation are a
thorough history, physical, and neurologic examination. If these are abnormal or
suspicious for a secondary etiology, then additional diagnostic testing is
performed.

An overview of the causes, evaluation, and management of headache in

children will be presented here. Emergency evaluation of headache in children,
specific primary headache syndromes in children, and headache related to
exertion are discussed separately:

●(See "Emergency department approach to nontraumatic headache in

children".)
●(See "Types of migraine and related syndromes in children".)
●(See "Pathophysiology, clinical features, and diagnosis of migraine in
children".)
●(See "Acute treatment of migraine in children".)
●(See "Tension-type headache in children".)
●(See "Exercise (exertional) headache".)

EPIDEMIOLOGY Headaches are common in children and

adolescents [3-5]. In a systematic review of 50 population-based studies, nearly

60 percent of children reported having had headaches over periods of time
(ranging from one month to "lifetime") [5]. By age 18 years, more than 90
percent of adolescents report having had a headache [3].
Recurrent severe headaches also are common in children. In the United States,
approximately 20 percent of children aged 4 to 18 years report having had
notable recurrent headaches (including migraine) in the past 12 months [6]. The
prevalence of recurrent headaches increases with age from 4.5 percent among
children 4 to <6 years to 27.4 percent among children 16 to 18 years [6]. In a
population-based study, 1.5 percent of middle school students (age 12 to 14
years) had "chronic daily headache" (15 headache days per month with chronic
migraine and chronic tension-type headaches making up the majority, and
chronic migraine most frequently presenting for evaluation) [7,8]. Other chronic
daily headaches include new daily persistent headache and chronic
posttraumatic headaches [9]. (See 'Migraine' below and "Chronic daily
headache: Associated syndromes, evaluation, and management", section on
'Definition'.)
Before 12 years of age, the prevalence of headaches is similar among males
and females (approximately 10 percent) [6]. After age 12 years, the prevalence
is higher in females (approximately 28 to 36 percent versus 20 percent) [4,6]. In
adults, the female to male ratio for migraine is approximately 3:1. Headaches
occur more often in children who have a family history of headaches in first- or
second-degree relatives [10-12].
The epidemiology of migraine and tension-type headaches in children is
discussed separately. (See "Pathophysiology, clinical features, and diagnosis of
migraine in children", section on 'Epidemiology' and "Tension-type headache in
children", section on 'Epidemiology'.)

ETIOLOGY Childhood headaches are rarely caused by a serious

underlying disorder [13]. The most common headache etiologies vary

depending upon the setting in which the child is evaluated.
Most children who present to pediatric emergency departments with acute
headache have a viral illness or an upper respiratory infection as the
symptomatic etiology of their headache. However, more serious conditions
occasionally are diagnosed, and primary headaches, especially status
migrainosus, also present to the emergency department [14-16]. As many as 90
percent of adults who have been diagnosed (self-diagnosed or diagnosed by a
clinician) with recurrent sinus headaches actually have migraine headaches
[17]. (See "Emergency department approach to nontraumatic headache in
children", section on 'Causes'.)
In the primary care setting, primary headaches (table 1) and infectious
etiologies are most common [18-20]. In a historical cohort of 48,575 children
aged 5 to 17 years who were seen by primary care providers for complaint of
headache, 19 percent were diagnosed with primary headache at the time of
presentation, 1.1 percent were diagnosed with secondary headache, and 79.7
percent received no formal diagnosis (5.4 percent of these were diagnosed with
primary headaches in the subsequent year) [20].
 CLASSIFICATION Headaches can be classified as primary (those in

which the head pain is due to the headache condition itself (table 1)) and
secondary (those in which the head pain is a symptom of an underlying
condition).

Primary headaches and secondary headaches are not mutually exclusive;

patients with a primary headache disorder can have a primary headache
exacerbated by a secondary etiology.

The International Classification of Headache Disorders, 3 rd edition (ICHD-3)

provides detailed diagnostic criteria for primary headaches, secondary
headaches, and facial pain disorders [9].
Primary headache — The most common primary headaches in children are
migraine and tension-type headache (table 1). Trigeminal autonomic
cephalalgias (including cluster headaches) are rare in children younger than 10
years and uncommon in older patients.
Migraine — Migraine is a disease characterized by intermittent attacks of
headache. Recognition that migraine is a disease in which headache is just one
of the symptoms is important. (A person does not have a "migraine," but rather
has a headache due to migraine.) An attack of migraine is characterized by
recurrent episodes of head pain that are typically moderate to severe in
intensity, lasting 2 to 72 hours if not treated, characterized by focal pain that is
throbbing and worsens with activity or causes avoidance of activity [9]. It can be
accompanied by nausea, vomiting, light sensitivity ("photophobia"), and sound
sensitivity ("phonophobia") (table 2A). In children, particularly young children,
the duration of headache is typically shorter than in adults, lengthening with
age. Migraines in children are most often bilateral (bifrontal or bitemporal).
Headaches that are occipital in location have an increased risk of a secondary
cause (although migraine remains the most common cause of occipital
headaches) and need to be investigated further. (See 'Worrisome
findings' below.)
The clinical features, diagnosis, and management of migraine in children are
discussed separately. (See "Pathophysiology, clinical features, and diagnosis of
migraine in children" and "Preventive treatment of migraine in
children" and "Acute treatment of migraine in children".)
Approximately 10 percent of children with migraine have associated auras that
include visual, sensory, speech/language, motor, brainstem, or retinal
symptoms (eg, scotoma), paresthesias, dysphasia, hemiplegia, weakness,
ataxia, or confusion [21].
Chronic migraine is the most common chronic headache condition in children
and adolescents. It is defined as headaches on 15 or more days per month,
with at least eight having migraine features. Chronic migraine is a considerable
problem in children. In a population-based study of middle school students (age
12 to 14 years), the overall prevalence was 1.5 percent [7]. Chronic migraine
was more common in females than males (2.4 versus 0.8 percent).
Avoidance of medication overuse is an important step in the prevention of
chronic migraine [22]. Medication overuse has been reported in 20 to 36
percent of adolescents with chronic headache and is an independent predictor
of chronic migraine persistence [7,23-25]. Discussion of medication overuse is
one of the key outcome metrics recommended by the American Academy of
Neurology [26]. Major depression is another independent predictor of highly
frequent headaches [25].
Episodic symptoms associated with migraine (formerly childhood periodic
syndromes or migraine "variants") have been reported to include benign
paroxysmal vertigo, cyclic vomiting, abdominal migraine, and colic. Benign
torticollis (recurrent, often short-lived, and spontaneously recovering attacks of
head tilt in infants) also has been proposed as a variant of migraine [27,28].
(See "Types of migraine and related syndromes in children", section on
'Episodic syndromes that may be associated with pediatric
migraine' and "Acquired torticollis in children", section on 'Benign paroxysmal
torticollis'.)
Tension-type headaches — Tension-type headaches (TTH) are characterized
by headaches that are diffuse in location, non-throbbing, mild to moderate
severity, and do not worsen with activity (although the child may not wish to
participate in activity). They can last from 30 minutes to 7 days (table 2B). TTH
may be associated with photophobia or phonophobia (but not both) but is not
accompanied by nausea, vomiting, or aura [9].
Although TTH may share clinical features with migraine, the ICHD-3 specifies
that migraine diagnosis takes priority over the diagnosis of TTH, so when in
doubt between the two, the diagnosis of migraine, rather than "mixed headache
disorder," should be made [9]. TTH in children are discussed separately.
(See "Tension-type headache in children".)
Cluster headaches — Cluster headaches constitute the most common
trigeminal autonomic cephalalgia. This group of headaches is characterized by
trigeminal location and association with autonomic features. Cluster headaches
are typically unilateral and frontal-periorbital in location (table 2C). The pain of
cluster headaches is severe and lasts less than three hours, but multiple
headaches occur in a very short period of time (hence "cluster"). Cluster
headaches usually are associated with ipsilateral autonomic findings, including
lacrimation, conjunctival injection, nasal congestion and/or rhinorrhea, facial and
forehead sweating, eyelid edema, and miosis and/or ptosis [9].
Cluster headaches have been reported in children as young as three years of
age, but they are rare in children younger than 10 years and uncommon in older
patients. They become more apparent between the ages of 10 and 20 years,
although they remain infrequent. Cluster headaches are discussed separately.
(See "Cluster headache: Epidemiology, clinical features, and diagnosis", section
on 'Clinical features'.)
Secondary headache — Secondary headaches are caused by an underlying
condition. They usually develop in close temporal relationship to the underlying
condition and usually successfully resolve with adequate treatment of the
condition. Secondary headaches include exacerbation of primary headaches by
an underlying condition [29].
Conditions that may cause secondary headache in children include [29]:
●Acute febrile illness (eg, influenza, upper respiratory infection, sinusitis)
(see "The common cold in children: Clinical features and
diagnosis" and "Acute bacterial rhinosinusitis in children: Clinical features
and diagnosis")
 Such infections are the most common cause of secondary headache in
children [14,15]. However, recurrent rhinosinusitis is one of the most
common misdiagnoses for headaches, with the majority actually being a
primary headache and usually migraine
●Posttraumatic headaches; acute posttraumatic headaches usually
resolve within seven to ten days (see "Intracranial epidural hematoma in
children: Clinical features, diagnosis, and management", section on
'Clinical features' and "Intracranial subdural hematoma in children: Clinical
features, evaluation, and management", section on 'Clinical features')
●Medications (given the frequency of headache as a complaint,
"headache" is listed on nearly every medication as a potential side effect)
●Medication overuse headache; frequent overuse of analgesic medication
is one of the most common causes of secondary chronic headache
●Acute and severe systemic hypertension (may cause headache or be a
response to increased intracranial pressure) (see "Evaluation of
hypertension in children and adolescents", section on 'Initial evaluation')
●Acute or chronic meningitis (see "Bacterial meningitis in children older
than one month: Clinical features and diagnosis", section on 'Clinical
features' and "Viral meningitis in children: Clinical features and diagnosis",
section on 'Clinical features')
●Brain tumor (see "Clinical manifestations and diagnosis of central
nervous system tumors in children", section on 'Clinical manifestations')
●Idiopathic intracranial hypertension (see "Idiopathic intracranial
hypertension (pseudotumor cerebri): Clinical features and diagnosis")
●Hydrocephalus (see "Hydrocephalus in children: Clinical features and
diagnosis", section on 'Clinical features')
●Intracranial hemorrhage (typically presents as sudden severe unilateral
headache)
Headache attributed to visual refractive error is included as a type of secondary
headache in the ICHD-3 [9]. However, in contrast to the secondary causes of
headache listed above, definitive evidence that visual refractive errors cause
headaches in children is lacking [30].

CLINICAL PRESENTATION Young children may express pain

differently than older children and adolescents and often are able to attenuate
or ignore pain through play [31,32]. Headache pain may not be apparent to
caregivers of younger children, who react by crying, rocking, or hiding, or
altered activity level. Chronic pain may be associated with anxiety, depression,
and behavior problems and affect the child's ability to eat, sleep, or play. Older
children are better able to perceive, localize, and remember pain. Emotional,
behavioral, and personality factors become more important as the child enters
adolescence.
The variability in presentation in children of different ages may lead to difficulty
when applying the standard headache diagnostic criteria (eg, International
Classification of Headache Disorders, 3rd edition [ICHD-3]) [9].
 EVALUATION The evaluation of headache in children includes a

thorough history (table 3), physical examination (table 4), and neurologic
examination with particular attention to the clinical features suggestive of
intracranial infection or space-occupying lesion (table 5). If the initial evaluation
is suspicious for secondary headache, additional diagnostic testing is
necessary. The neurologic examination is the most sensitive indicator of
needing further evaluation, including neuroimaging. The headache pattern may
help to suggest the etiology. (See 'Headache pattern' below.)
Headache history — The headache history provides most of the necessary
diagnostic information in the evaluation of childhood headaches (table 3). A
thorough history helps to focus the physical examination and prevent
unnecessary investigation and neuroimaging.
The history of headache for a child should initially be obtained from the child
and confirmed by the caregivers. In young children, caregiver observation of
behavior can support the diagnostic criteria. Asking young children to "draw the
headache" may assist in the diagnosis when the child is not able to express the
headache characteristics in words. Children, adolescents, and young adults
may be prone to the childhood periodic syndromes/episodic syndromes
associated with headache. This includes motion sickness, sleep walking, sleep
talking, night terrors, unexplained fevers, recurrent abdominal pain, and
episodes of anxiety. Motion sickness precipitated by reading in a car is a
common feature in migraine sufferers [33,34].
A diary in which the quality, location, severity, timing, precipitating and palliating
factors, and associated features of the headache are recorded prospectively
may be a useful adjunct if the child is willing and able to complete on a daily
basis. A diary is not subject to recall error, may reveal a pattern that is typical
for a certain type of headache, and provides important diagnostic information for
children who are unwilling or unable to provide sufficient detail during the office
interview [35,36].
Headache pattern — Determining if a headache is new or represents a
recurrent problem is useful in differentiating primary from secondary headaches.
Most primary headaches are episodic headaches that may transform to more
frequent headaches (chronification). Asking about all headaches, not just the
one that is being brought to attention, can help identify this pattern. An acute
change in an underlying recurrent, episodic headache disorder is a potentially
concerning pattern.
Physical examination — Important aspects of the physical examination in a
child with headache are described in the table (table 4) [37].
The physical examination, including the funduscopic examination, is usually
normal in children with primary headaches (eg, migraine, tension-type
headache). (See "Pathophysiology, clinical features, and diagnosis of migraine
in children", section on 'Diagnosis' and "Tension-type headache in children",
section on 'Examination'.)

Although the physical examination is also typically normal in secondary

headaches, when the physical or especially the neurologic examination is
abnormal, secondary headaches must be considered and the examination
findings may provide clues to the underlying diagnosis (eg, fever and nuchal
rigidity in a child with meningitis). Abnormal funduscopic examination requires
additional evaluation, as indicated by the findings from the history and physical
examination. In most cases of brain tumor-induced headache, some aspect of
the neurologic examination is abnormal.

Worrisome findings — Predictors for intracranial pathology (ie, space-

occupying lesion or central nervous system infection) have been identified in
small observational studies (table 5) [38-43]. It is particularly important to ask
about and look for these symptoms and signs of increased intracranial
pressure, intracranial infection, and progressive neurologic disease. Worrisome
findings are an indication for further evaluation and/or neuroimaging.
(See "Elevated intracranial pressure (ICP) in children: Clinical manifestations
and diagnosis", section on 'Clinical manifestations'.)
Neuroimaging — Neuroimaging studies may detect a variety of disorders that
cause secondary headache, including congenital malformations,
hydrocephalus, intracranial infections and their sequelae, trauma and its
sequelae, neoplasms, vascular disorders (such as arteriovenous
malformations), and intracranial thrombosis. However, most children who
present to primary care have signs and symptoms consistent with primary or
uncharacterized headaches and do not require neuroimaging [20].
Indications — Decisions regarding neuroimaging in children with headaches
should be made on a case-by-case basis [44].
Children with an abnormal neurologic examination, children younger than six
years, or children who have features worrisome for a pathologic intracranial
process (table 5) generally should undergo neuroimaging with magnetic
resonance imaging (MRI) (see 'Which imaging study?' below). Neuroimaging
also is indicated for severe headache in a child with an underlying disease that
predisposes to intracranial pathology (eg, immune deficiency, sickle cell
disease, neurofibromatosis, history of neoplasm, coagulopathy, hypertension)
[43-45]. Although occipital headaches are classically considered to be a
worrisome feature, two small observational studies question whether
neuroimaging is necessary in children with occipital headaches and no other
worrisome features [46,47]. Pending verification of these results in larger
studies, we continue to consider occipital headaches a worrisome feature.
Neuroimaging for children with acute head trauma, suspected infection (eg,
sinusitis, meningitis, encephalitis), or other obvious cause is discussed in
greater detail separately. (See "Acute bacterial rhinosinusitis in children: Clinical
features and diagnosis", section on 'Diagnosis' and "Bacterial meningitis in
children older than one month: Clinical features and diagnosis", section on
'Neuroimaging' and "Acute viral encephalitis in children: Clinical manifestations
and diagnosis", section on 'Neuroimaging'.)
Neuroimaging of children with headaches in the absence of neurologic
abnormalities on examination and/or symptoms of neurologic abnormalities on
history has a low yield of clinically significant findings (0.9 to 1.2 percent)
[43,48,49]. Neuroimaging of such children may detect incidental findings that
require additional evaluation or follow-up [45,48,50-52]. Other potential adverse
effects of neuroimaging include radiation exposure, exposure to anesthesia if
sedation is required, and false reassurance from an inadequate study [44].
Most children who present to primary care with headaches have primary or
uncharacterized headaches and do not require neuroimaging [20].
Neuroimaging generally is not indicated for children with a history of recurrent,
episodic headaches that have persisted for greater than six months and who
have no signs or symptoms of neurologic dysfunction or increased intracranial
pressure [43,44]. Headache features and frequency may vary with time, so the
full history must be utilized to guide neuroimaging decision making.
Neuroimaging also is usually not indicated for children with migraine who lack
neurologic abnormalities. However, it may be difficult to differentiate early
migraine episodes from headache secondary to a space-occupying lesion
because the International Classification of Headache Disorders (ICHD) criteria
for migraine will not have been met, as five headache episodes are required
(table 2A) [43].
The yield of neuroimaging in detecting clinically significant intracranial
abnormalities in children without neurologic abnormalities is extremely low. In a
systematic review of six studies in which 605 of 1275 children with recurrent
headaches underwent neuroimaging, imaging abnormalities were found in 97
children (16 percent) [38,43,53-57]. However, in 79 of these children, the
abnormalities did not require further intervention. Among the remaining 18
children, 14 had lesions requiring surgery (10 tumors, three vascular
malformations, one arachnoid cyst with mass effect), and four had lesions that
required medical treatment. All of the children who had surgically treatable
lesions had abnormal findings on neurologic examination, including
papilledema, abnormal eye movements, or motor or gait dysfunction.
Our indications for neuroimaging in children with headache are consistent with
the guidelines from the American Academy of Neurology (AAN), the American
College of Radiology, and the multidisciplinary United States Headache
Consortium [43-45].
Timing — The level of urgency is determined by the status of the patient and
the speed with which the situation is evolving [18]. Urgent neuroimaging is
reserved for patients with signs of increased intracranial pressure and/or focal
neurologic examination with concern for a space-occupying lesion (eg, brain
tumor or brain abscess) or intracranial hemorrhage. (See 'Which imaging
study?' below.)
Which imaging study? — Brain MRI is usually preferred. Head computed
tomography (CT) is performed if MRI is not available or imaging is needed
immediately (eg, suspected acute hemorrhage, rapid diagnosis of space-
occupying lesion). MRI with gadolinium or CT with contrast should be performed
if the clinician suspects an inflammatory cause or breakdown of the blood-brain
barrier (eg, abscess or tumor).
MRI is usually preferred in nonacute situations (or if there is persistent concern
despite a normal head CT scan) because it minimizes radiation exposure and is
more sensitive than CT [58]. MRI demonstrates sellar lesions, craniocervical
junction lesions, posterior fossa lesions, white matter abnormalities, and
congenital anomalies more reliably than does CT. However, in young children,
MRI may require sedation, which CT usually does not.
MR angiography or CT angiography may be indicated if subarachnoid blood or
parenchymal blood is identified on initial MRI, CT, or lumbar puncture [45].
(See 'Lumbar puncture' below.)
Laboratory evaluation — Laboratory testing rarely is helpful in the evaluation
of childhood headache and is predominantly used to differentiate causes of
secondary headache [36,43,59]. The AAN practice parameter indicates that the
evidence is insufficient to support any recommendation regarding the value of
routine laboratory studies or lumbar puncture in the evaluation of recurrent
headache in children [43].
Lumbar puncture — Lumbar puncture (LP) generally should be performed in
children in whom intracranial infection, subarachnoid hemorrhage, or idiopathic
intracranial hypertension (pseudotumor cerebri) is suspected. Neuroimaging
typically is performed before LP because LP is contraindicated in patients with
space-occupying lesions. However, in patients in whom bacterial meningitis is
suspected, the risks of delaying the LP and administration of antibiotics while
awaiting neuroimaging must be considered. (See "Lumbar puncture:
Indications, contraindications, technique, and complications in children", section
on 'Indications' and "Lumbar puncture: Indications, contraindications, technique,
and complications in children", section on 'Contraindications'.)
Patients in whom idiopathic intracranial hypertension is suspected may require
reassurance or sedation before undergoing the lumbar puncture because an
accurate opening pressure measurement is crucial to the diagnosis. Inadequate
technique (eg, Valsalva, straining, crying) can cause artifactually high opening
pressure measurements. (See "Idiopathic intracranial hypertension
(pseudotumor cerebri): Clinical features and diagnosis", section on 'Lumbar
puncture'.)
Other tests — Other tests should be performed as indicated to evaluate
suspected underlying medical conditions. These tests should be tailored to
evaluate conditions suggested by information from the history and examination.
Examples include [18]:
●Complete blood count with differential and erythrocyte sedimentation rate
(if infection, anemia, vasculitis, or malignancy is suspected)
●Serum or urine toxicology screens (if acute or chronic intoxication is
suspected)
●Thyroid function tests (if thyroid dysfunction is suspected) (see "Acquired
hypothyroidism in childhood and adolescence", section on
'Diagnosis' and "Clinical manifestations and diagnosis of Graves disease
in children and adolescents", section on 'Diagnostic evaluation')
Electroencephalography — Electroencephalography is not recommended in
the routine evaluation of a child with recurrent headaches and typically has no
role to play [43]. It is unlikely to be useful in determining the cause of headache
or in distinguishing migraine from other types of headache.

DIAGNOSIS The diagnosis of primary headache disorders is made

clinically, based upon the International Classification of Headache Disorders,

3rd edition [9]:
●Migraine (table 2A) (see 'Migraine' above)
●Tension-type headache (table 2B) (see 'Tension-type headaches' above)
●Trigeminal autonomic cephalalgias, including cluster headaches (table
2C) (see 'Cluster headaches' above)
The diagnosis of a chronic headache is also made clinically in children with
headache on more than 15 days a month for more than three months in the
absence of detectable organic pathology and is based on the predominant
headache features with chronic migraine trumping chronic tension-type
headache [8]. (See 'Migraine' above.)
The diagnosis of secondary headaches depends upon identification of the
underlying condition. (See 'Secondary headache' above.)

MANAGEMENT The management of recurrent and chronic headache

in children and adolescents depends upon the underlying etiology. The

management of migraine and tension-type headaches is discussed separately.
(See "Acute treatment of migraine in children" and "Tension-type headache in
children", section on 'Treatment'.)
Some management components of recurrent headache disorders include [60-
63]:
●Providing realistic expectations (ie, the frequency and severity of the
headaches may decrease over weeks to months of therapy, but the
headaches may continue to occur) (see 'Outcome' below)
●Return to school for children who have been absent; if necessary, they
can go to the school nurse or office once daily for 15 minutes when
headache pain peaks
●Avoidance of headache triggers (eg, dietary triggers, caffeine, lack of
sleep, inadequate hydration, overuse of electronic devices)
●Daily exercise for 20 to 30 minutes
●Addressing comorbid sleep problems (eg, delayed sleep onset, frequent
night waking), mood problems, and/or anxiety
Additional nonpharmacologic approaches may be beneficial. Cognitive
behavioral therapy and biofeedback-assisted relaxation therapy including
guided imagery, progressive muscle relaxation, and deep breathing have some
evidence of benefit, while other treatments, including physical therapy,
acupuncture, hypnosis, meditation, and massage, may be helpful but are
unproven [61,64-66].
The use of acute medications is a key component of treatment and should
include early recognition and addressing barriers to treatment, use of
multimechanism care when primary acute medication is incompletely effective
and avoidance of medication overuse. Preventive medications may be
necessary for children with headaches that occur more than four times per
month or headaches that adversely affect the child's activities [61].

When medication overuse is identified (>15 days per month of over-the-counter

medication or >10 days per month of prescription medication) discontinuation of
all analgesic medications is indicated.

Several devices have been approved by the US Food and Drug Administration
for the acute and preventive treatment of headaches due to migraine. These
devices, which provide mild electrical stimulation to the face, head, or upper
arm, offer the additional benefit of allowing the patient to have an increased
locus of control, while avoiding the need to swallow medications.

Acute and preventive agents (eg, calcitonin gene-related peptide monoclonal

antibodies, gepants, ditans) have been approved for adults and are under study
in children and adolescents. The use of these agents in adults is discussed
separately. (See "Preventive treatment of episodic migraine in adults", section
on 'CGRP antagonists' and "Estrogen-associated migraine, including menstrual
migraine", section on 'Triptans, ditans, and CGRP antagonists'.)

INDICATIONS FOR REFERRAL Primary care providers can

usually manage children and adolescents with acute, recurrent, episodic, and
chronic headaches. Indications for referral may include [18,67]:
●Secondary headache requiring specialist management (eg, space-
occupying lesions, idiopathic intracranial hypertension)
●Headaches associated with mood disturbance or anxiety
●Uncertain diagnosis
●Headaches refractory to primary care management
●Very frequent headaches unresponsive to typical therapy (ie, chronic
migraine or chronic tension-type headaches)
●The need for more intensive management that can only be provided by a
multidisciplinary headache program

OUTCOME Headache that begins in childhood often changes in its

characteristics with time and may remit or improve. In one study, 100 children
and adolescents with headache were seen eight years after the initial visit [68].
Remission occurred in 44 percent of children with tension headache and in 28
percent of children with migraine. Migraine without aura persisted in the same
form in 44 percent and became episodic tension headache in 26 percent.
Episodic tension headache persisted in the same form in 26 percent and
changed to migraine without aura in 11 percent. Psychiatric comorbidity at the
initial visit was associated with worsening or unchanged clinical status at follow-
up [69].
In another long-term study of 103 children with chronic headache (>15
headaches per month), frequent headaches persisted in 25 percent at two
years and 12 percent at eight years [70]. Early onset was associated with a
protracted disease course.

RESOURCES

●The American Migraine Foundation provides information and resources

for patients and providers.
●The American Headache Society provides resources for clinicians.
●The National Headache Foundation provides information and resources
for patients and providers.

INFORMATION FOR PATIENTS UpToDate offers two types of

patient education materials, "The Basics" and "Beyond the Basics." The Basics
patient education pieces are written in plain language, at the 5 th to 6th grade
reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10 th to 12th grade reading level and are
best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or email these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
"patient education" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Headaches in children (The

Basics)" and "Patient education: Migraines in children (The Basics)")
●Beyond the Basics topic (see "Patient education: Headache in children
(Beyond the Basics)")

SUMMARY

●Epidemiology – Approximately 20 percent of children aged 4 to 18 years

have had frequent or severe headaches in the past 12 months.
(See 'Epidemiology' above.)
●Etiology – Headache in children and adolescents may be due to a
primary headache disorder (ie, migraine, tension-type headache,
trigeminal autonomic cephalalgias (table 1)) or secondary to an underlying
medical condition.
Secondary headaches usually are related to fever or infection (eg, upper
respiratory infection, influenza) but may be due to central nervous system
infection or space-occupying lesion. (See 'Etiology' above.)
●Evaluation
•The evaluation of headache in children includes a thorough history
(table 3), physical examination (table 4), and neurologic examination,
with particular emphasis on clinical features suggestive of intracranial
pathology (table 5). The headache pattern helps to determine the
etiology. (See 'Evaluation' above.)
•Neuroimaging should be performed in children with headache and
neurologic signs or symptoms suggestive of intracranial pathology
(table 5). Brain MRI is usually preferred. Head CT is performed if MRI
is not available or imaging is needed immediately (eg, suspected acute
hemorrhage, rapid diagnosis of space-occupying lesion). MRI with
gadolinium or CT with contrast should be performed if the clinician
suspects an inflammatory cause or breakdown of the blood-brain
barrier (eg, abscess, tumor). (See 'Neuroimaging' above.)
•Routine laboratory evaluation usually is not necessary for children
with recurrent or chronic headaches. The laboratory evaluation for
secondary headache should be tailored to evaluate conditions
suggested by information from the history and examination.
(See 'Laboratory evaluation' above.)
●Diagnosis – The diagnosis of primary headache disorders is made
clinically, based upon the criteria of the International Classification of
 Headache Disorders (table 2A-C). The diagnosis of chronic headache
also is made clinically (headache on >15 days per month for >3 months in
the absence of detectable organic pathology). The diagnosis of secondary
headaches depends upon identification of the underlying condition.
(See 'Diagnosis' above.)
●Management – The treatment of recurrent and chronic headaches
requires a systematic approach over several months through which the
child returns to normal activities of daily living. It is critical to address
excessive school absence and overuse of over-the-counter analgesic
medications. (See 'Management' above.)

ACKNOWLEDGMENT The UpToDate editorial staff acknowledges

Andrew G Lee, MD, who contributed to an earlier version of this topic review.

Emergency department approach to

nontraumatic headache in children
Author:
Richard A Saladino, MD
Section Editors:
Marc C Patterson, MD, FRACP
Sanghamitra M Misra, MD, MEd
Deputy Editor:
James F Wiley, II, MD, MPH
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Sep 2022. | This topic last updated: Nov 04, 2021.

INTRODUCTION This topic will discuss the emergency department

(ED) approach to nontraumatic headache in otherwise healthy children.

Children with nontraumatic headaches who present non-urgently and those with
well-established histories of migraine or tension-type headaches are discussed
separately. (See "Headache in children: Approach to evaluation and general
management strategies" and "Pathophysiology, clinical features, and diagnosis
of migraine in children" and "Tension-type headache in children".)

EPIDEMIOLOGY Headache is the most common neurologic

complaint in the pediatric population and a common presenting complaint in the

emergency department (ED). Although most children with headache do not
seek medical attention, the prevalence of headache in children is increasing, as
are ED visits and hospitalizations [1-4]. Caretakers may bring children to the ED
or a primary care provider for headaches that are more severe or have not
responded to nonprescription medications. In the pediatric ED, nontraumatic
headaches account for up to 2.5 percent of visits [5-7].

The terms "primary" and "secondary" are used to describe headache etiology:

●Primary headaches – Primary headaches comprise 90 percent of all

pediatric headaches [8] (ie, migraine, tension-type, or cluster headaches),
are typically self-limited, and are diagnosed based on symptom profiles
and patterns of headache attacks (table 1).
●Secondary headaches – Secondary headaches have identifiable
underlying conditions. Although the vast majority of secondary headaches
in children have benign etiologies (eg, acute febrile viral illness), the goal
of the emergency evaluation of children with headaches is to identify as a
first priority those with serious or life-threatening causes such as central
nervous system infection, brain tumor, intracranial hemorrhage, or severe
hypertension [8-12]. In most patients, this task can be accomplished with
a careful history and physical examination and selected ancillary testing.
The prevalence of serious or life-threatening intracranial conditions in
children presenting to the ED with nontraumatic headache ranges from 1
to 10 percent, depending upon the clinical findings [13,14].
Headache can be the symptom of life-threatening complications for children
with various underlying conditions (eg, those with indolent, progressive, or
unsuspected head trauma; immunodeficiencies who develop opportunistic
infections; or patients with ventriculoperitoneal shunts that malfunction, causing
obstruction). Evaluation of headache in these children is often guided by
specific protocols that include neuroimaging and consultation with a specialist
(eg, neurosurgeon, infectious disease specialist, or oncologist).
(See "Hydrocephalus in children: Management and prognosis", section on
'Shunt complications' and "Pathogenesis, clinical manifestations, and diagnosis
of brain abscess".)

CAUSES The most important consideration in the evaluation is to

differentiate between primary and secondary headache. The majority of children

who undergo emergency evaluations for headaches are diagnosed with viral
illnesses or migraine headaches [5,6,15,16]. This epidemiology is similar to the
causes of headache among children seen in primary care settings and adults
seen in emergency departments (EDs) [17,18]. The challenge for the
emergency clinician is to identify patients with secondary headaches who
require rapid diagnosis and treatment (table 2).
Life-threatening conditions — Life-threatening causes of headache are those
that may result in brain injury or death from various mechanisms including brain
tumor, inflammation, increased intracranial pressure (ICP), and/or hypoxia.
Infection — Children with life-threatening infections as the cause of headache
typically have other worrisome clinical features, such as altered mental status or
focal neurologic findings. These manifestations may be subtle in younger
children who cannot describe their symptoms.
 ●Bacterial meningitis – The irritable or lethargic child with fever, neck
pain/stiffness, and/or headache may have bacterial meningitis. The
incidence of bacterial meningitis among children has declined since the
introduction of conjugate vaccines against Haemophilus influenza type
B and Streptococcus pneumoniae. (See "Bacterial meningitis in children
older than one month: Clinical features and diagnosis", section on 'Clinical
features'.)
●Other non-viral meningitis – The differential diagnosis of headache is
not complete without consideration of rare causes of meningitis:
•Tuberculous meningitis occurs in patients who have or have had
tuberculosis and should be considered in the context of a history of
possible exposure to Mycobacterium tuberculosis and signs of
meningitis, including fever, headache, and nuchal rigidity.
(See "Central nervous system tuberculosis: An overview".)
•Fungal meningitis is considered in the immunocompromised host who
presents with signs of meningitis, including headache. (See "Candida
infections of the central nervous system" and "Coccidioidal
meningitis" and "Epidemiology, clinical manifestations, and diagnosis
of Cryptococcus neoformans meningoencephalitis in patients with
HIV".)
●Viral encephalitis – Progressive symptoms of fever, headache, and
abrupt onset of altered sensorium (eg, bizarre behavior, visual or auditory
hallucinations) are associated with viral encephalitis. In otherwise healthy
children, herpes simplex virus causes 10 to 20 percent of sporadic cases
of encephalitis and is the only treatable pathogen in this condition.
Infection with specific arthropod-borne viruses may be suggested by
seasonal patterns (eg, Eastern equine encephalitis or West Nile virus) or
recent travel. (See "Herpes simplex virus type 1
encephalitis" and "Arthropod-borne encephalitides".)
●Orbital or cerebral abscess – Children with focal infections, such as
orbital or cerebral abscesses, typically have focal findings on ocular
and/or neurologic examination. Conditions that may be associated with
central nervous system abscess formation include immunocompromise
and congenital heart disease with right-to-left intracardiac shunting.
Cerebral abscess and cerebral venous thrombosis are uncommon but life-
threatening complications of orbital, sinus, ear, or dental infections [19,20].
(See "Orbital cellulitis" and "Bacterial meningitis in children: Neurologic
complications" and "Cerebral venous thrombosis: Etiology, clinical
features, and diagnosis", section on 'Risk factors and associated
conditions'.)
Tumor — Chronic progressive headache (increasing in frequency and severity
over time) is a common presenting symptom among children with brain tumors.
Nocturnal or morning headache, especially when associated with vomiting, is
also prevalent in children with brain tumors (see "Brain tumor headache",
section on 'Clinical features'). However, very few children evaluated in the ED
for headache have brain tumors as the cause. In a large multicenter pediatric
series describing children with brain tumors, 62 percent of patients had
headaches at the time of diagnosis [21]. In comparison, in a small prospective
series, less than 3 percent of children presenting to the ED with headaches had
newly diagnosed brain tumors [15].
The early symptoms of brain tumors are often nonspecific, and diagnosis may
be delayed [22]. At the time of diagnosis, the overwhelming majority of children
with brain tumors as the cause have other symptoms in addition to headache
[23]. Over 99 percent of children in the multicenter report and all of the children
in the ED series had at least one other symptom or sign (eg, nausea/vomiting,
visual disturbance, ataxia, or abnormal eye movements) [15,21].
Subarachnoid and intracranial hemorrhage — Nontraumatic intracranial
hemorrhage (typically subarachnoid) can develop in association with an
aneurysm, vascular malformation, coagulopathy, or hemoglobinopathy. The
patient may report the abrupt onset of headache, which reaches maximal
intensity in less than one minute. In one retrospective series that described
children with nontraumatic intracranial hemorrhage, more than half presented
with headache and vomiting [24]. Frequent signs included hemiparesis and
seizures. Among patients with sickle cell disease, intracranial hemorrhage
accounts for about one-third of cerebrovascular events. (See "Acute ischemic
and hemorrhagic stroke in sickle cell disease".)
Intracranial hemorrhage is an uncommon but life-threatening cause of
headache among children. Headache is rarely the sole manifestation of
hemorrhage that occurs as the result of trauma (ie, epidural or subdural
hematoma). (See "Severe traumatic brain injury (TBI) in children: Initial
evaluation and management" and "Child abuse: Evaluation and diagnosis of
abusive head trauma in infants and children".)
Acute obstructive hydrocephalus — Acute obstructive hydrocephalus causes
an abrupt rise in intracranial pressure with one or more of the following findings:
●Headache
●Vomiting
●Lethargy or coma
●Hypertension with bradycardia or tachycardia
●Signs of transtentorial herniation (table 3)
Acute obstructive hydrocephalus may occur in patients with central nervous
system (CNS) infection, space-occupying lesions such as tumor or hemorrhage,
hydrocephalus, and cerebrospinal fluid shunt malfunction (see "Hydrocephalus
in children: Management and prognosis", section on 'Shunt malfunction'), and,
less commonly, as a presenting feature of selected brain malformations (eg,
Chiari type I or Dandy-Walker malformation). (See "Chiari
malformations" and "Prenatal diagnosis of CNS anomalies other than neural
tube defects and ventriculomegaly", section on 'Dandy-Walker malformation'.)
Carbon monoxide poisoning — Symptoms of mild to moderate carbon
monoxide (CO) poisoning are nonspecific but typically include headache [25].
Children may develop CO poisoning from occult sources, such as improperly
vented home heating systems, space heaters, or automobile exhaust fumes.
(See "Carbon monoxide poisoning".)
Hypertensive urgency or emergency — Patients with hypertensive crisis may
present with headache as one manifestation of hypertensive encephalopathy.
Other symptoms include visual changes from retinal hemorrhage or exudates,
altered mental status, and seizures. Hypertensive encephalopathy is
uncommon among children and is typically caused by systemic illness or
renovascular disease. Pheochromocytoma is an exceptionally rare pediatric
tumor that usually presents with headache, pallor, diaphoresis, and
hypertension. (See "Approach to hypertensive emergencies and urgencies in
children", section on 'Initial stabilization' and "Pheochromocytoma and
paraganglioma in children".)
Common conditions
Infection — Among children evaluated in the ED for headache, infection is the
most common cause [5,15,16].
●Fever – Children with fever (related almost entirely to infection)
frequently complain of headache. Headaches associated with fever are
thought to be due to vasodilation [26].
●Viral meningitis – Headache, with or without neck discomfort, is a
typical presentation of viral meningitis among older children and
adolescents. Other clinical manifestations (eg, rash or mouth lesions with
enterovirus) may suggest a specific virus. (See "Viral meningitis in
children: Clinical features and diagnosis", section on 'Clinical features'.)
●Lyme meningitis – In endemic regions (figure 1), Lyme meningitis is an
important diagnostic consideration in children with headache. The
presentation of Lyme meningitis is similar to that of aseptic meningitis.
Erythema migrans (by history or examination), cranial nerve palsy, and
papilledema (from increased ICP) are strongly associated with Lyme
meningitis but uncommon in patients with viral meningitis. (See "Lyme
disease: Clinical manifestations in children", section on 'Meningitis'.)
●Pharyngitis – Headache, sore throat, and abdominal pain are the classic
symptoms of streptococcal pharyngitis. Influenza virus infection can cause
similar symptoms, including headache. (See "Group A streptococcal
tonsillopharyngitis in children and adolescents: Clinical features and
diagnosis", section on 'Clinical features'.)
●Other – Otitis media, sinusitis, and dental infections can cause
headache. Localized pain and signs of inflammation suggest the specific
diagnosis. (See "Acute bacterial rhinosinusitis in children: Clinical features
and diagnosis", section on 'Complications' and "Acute otitis media in
children: Clinical manifestations and diagnosis", section on 'Clinical
presentation'.)
Migraine — In several observational series describing children evaluated in
EDs for acute headache, migraine was second only to viral illness as the cause
[2,3,15,16,27]. Migraine headaches are typically recurrent and episodic, with
characteristic patterns that are easily described by patients or parents (table
4 and table 1) [28,29]. A family history of migraine or headaches is common.
Children with significant changes in the quality, severity, or timing of headaches
should be carefully evaluated for other causes. (See "Pathophysiology, clinical
features, and diagnosis of migraine in children".)
Tension-type headache — Tension-type headache is the term designated by
the International Headache Society to describe what were previously called
tension, muscle-contraction, stress, or psychogenic headaches. Tension-type
headaches occur in 10 to 25 percent of schoolchildren and adolescents, making
them as common as migraine headaches [30]. Among children, they appear to
be associated with depression, oromandibular dysfunction, and muscle tension
due to stress [31].
In contrast with headaches related to brain tumors, pain is typically intermittent
and recurring (but nonprogressive), and the neurologic examination is
unremarkable (table 5). (See "Tension-type headache in children", section on
'Differential diagnosis'.)
Other conditions
Temporomandibular joint dysfunction — Temporomandibular joint (TMJ)
dysfunction occurs in children with primary and mixed dentition. Children
typically report increased pain while chewing and have point tenderness over
the mandibular condyle [32]. Headache occurs more frequently among older
children [33].
Idiopathic intracranial hypertension — Patients with idiopathic intracranial
hypertension (IIH) have papilledema, increased ICP with normal cerebrospinal
fluid (CSF) content, normal neuroimaging, the absence of neurologic signs
except cranial nerve VI palsy, and no known cause. Headache is the most
common chief complaint among children who are old enough to describe their
symptoms. Although IIH has been described in young children, most patients
are adolescents and typically female. (See "Idiopathic intracranial hypertension
(pseudotumor cerebri): Clinical features and diagnosis".)
Trigeminal autonomic cephalalgia (eg, cluster headache) — Cluster
headaches make up the most common trigeminal autonomic cephalalgia. This
group of headaches is characterized by trigeminal location and association with
autonomic features. Cluster headaches are typically unilateral and frontal-
periorbital in location (table 6). The pain of cluster headaches is severe and
lasts less than three hours, but multiple headaches occur in a very short period
of time (hence "cluster"). Cluster headaches usually are associated with
ipsilateral autonomic findings, which may include one or more of the following:
lacrimation, rhinorrhea, ophthalmic injection, and occasionally Horner syndrome
(ipsilateral miosis, ptosis, and facial anhidrosis).
Cluster headaches have been reported in children as young as three years of
age, but they are rare in children younger than 10 years of age and uncommon
in older patients. They become more apparent between the ages of 10 and 20
years, although they remain infrequent. Cluster headaches are discussed
separately. (See "Cluster headache: Epidemiology, clinical features, and
diagnosis", section on 'Clinical features'.)
Visual refractive errors — Although a rare cause of headache, visual
refractive errors (anisometropia, myopia, and hyperopia) can cause chronic,
fronto-orbital headaches that progress throughout the day in children [34,35].
Optical correction results in resolution in most cases. However, visual refractive
errors remain a diagnosis of exclusion for chronic headaches in children; more
urgent evaluation of signs or symptoms suggesting increased intracranial
pressure should not be delayed while waiting for an ophthalmologic
consultation.
Vision screening and detection of visual refractive errors in children are
discussed in greater detail separately. (See "Vision screening and assessment
in infants and children" and "Refractive errors in children".)

EVALUATION Patients with underlying conditions, such as

ventriculoperitoneal shunts or immunodeficiencies, who develop headaches

must receive thorough evaluations in accordance with specialized protocols
developed for those conditions. For most other children receiving emergency
evaluation for acute headache, the combination of history and physical findings,
with selective laboratory testing and neuroimaging, generally identifies those
patients with significant underlying conditions (eg, meningitis or intracranial
pathology) [8,15,16,27].

The remainder of this discussion will focus on the emergency evaluation

specific to children with headache, including identification of those patients with
serious causes of headache.

Stabilization — Rapid recognition of life-threatening causes of nontraumatic

headache is important because these patients often require stabilization and
rapid treatment of the underlying cause as described in the following algorithms
and/or rapid overview tables:
●Intracranial hypertension (algorithm 1) (see "Elevated intracranial
pressure (ICP) in children: Management")
●Bacterial meningitis (table 7) (see "Bacterial meningitis in children older
than one month: Treatment and prognosis")
●Carbon monoxide poisoning (table 8 and algorithm 2) (see "Carbon
monoxide poisoning")
●Hypertensive urgency or emergency (algorithm 3 and algorithm 4)
(see "Initial management of hypertensive emergencies and urgencies in
children")
History — An accurate history is an essential tool in the initial approach to
nontraumatic headache in children.
Patient age — Headaches in children younger than six years of age are more
likely to be caused by an underlying condition, most commonly a febrile viral
illness.
Headache characteristics — Characteristics of the headache that may help to
identify a cause include the following:
●Mode of onset – The abrupt onset of an extremely painful headache
(thunderclap, "worst headache of my life") may represent an intracranial
hemorrhage (eg, from an arteriovenous malformation or aneurysm).
However, when this symptom occurs in isolation (ie, without neck pain or
stiffness), it is nonspecific [13]. Thunderclap headache is rare in children,
accounting for <1 percent of pediatric emergency department (ED)
presentations for headache in one retrospective study [36].
(See 'Subarachnoid and intracranial hemorrhage' above and "Overview of
thunderclap headache".)
In addition, precipitation or worsening of the headache with a Valsalva
maneuver or exercise has been proposed as a potential symptom of
increased intracranial pressure [8].
●Timing – Tension-type headaches typically develop late in the day and
rarely cause a patient to awaken from sleep.
●Positional – A positional headache is one that presents or worsens upon
lying down, awakens the child from sleep, or occurs soon after awakening
in the morning [13]. A positional headache should raise concern about
increased intracranial pressure or a space-occupying brain lesion,
especially if it is accompanied by morning vomiting.
●Severity/quality – Descriptions from children of the severity and quality
of headache pain may not be as useful for identifying a cause as those
obtained from older patients. This was demonstrated in one prospective
study describing children evaluated in an ED for headache in which 98
percent of children selected the most severe rating on a pain scale to
 describe the severity of their headaches [5]. In this study, children with
upper respiratory infections were more likely to be able to describe the
quality of headache pain than those with brain tumors and
ventriculoperitoneal shunt malfunctions.
When able to describe the headache, the following characteristics are
helpful in identifying an etiology:
•Laterality – Unilaterality suggests migraine headache, although in
children under age 10 years, the pain in this condition may be bilateral.
Also, unilateral headaches occur with focal infections, such as
sinusitis.
•Location – Cluster headaches are usually temporal or retro-orbital in
location. Pain may also localize to specific regions in secondary
headaches, such as with sinusitis or dental abscess.
●Pattern of previous headaches – The following temporal headache
patterns often suggest a specific diagnosis:
•Acute – This pattern describes a single episode of headache without
a history of previous events. Acute headaches are typically secondary
headaches, often caused by febrile viral infections.
•Acute recurrent – These headaches typically have consistent
characteristics that are easily described by patients or parents. They
are usually primary headaches (ie, migraine or tension-type) (table 5)
(see 'Common conditions' above). Children with significant changes in
the quality, severity, or timing of headaches should be carefully
evaluated for other causes.
•Chronic progressive – Chronic progressive headaches increase in
frequency and severity over time. This is a worrisome pattern
associated with space-occupying lesions such as brain tumors,
abscesses, or hemorrhage. (See 'Life-threatening conditions' above.)
•Chronic nonprogressive – Frequent persistent headaches that have
not changed in character are usually tension-type headaches.
Associated symptoms — The following additional historical features may
suggest a specific diagnosis:
●Fever – The majority of children who are evaluated in EDs for headache
have some type of infection (viral upper respiratory infections, sinusitis, or
streptococcal pharyngitis) [15,16].
●Neck pain or altered mental status – Meningeal signs and/or an abrupt
change in mental status suggest subarachnoid hemorrhage (typically with
abrupt onset of "worst headache of my life") or, when accompanied by
fever, life-threatening infections such as meningitis or encephalitis.
(See 'Life-threatening conditions' above.)
●Localized pain – Children with localized pain may have specific
infections, such as pharyngitis, otitis media, sinusitis, or dental infections.
(See 'Common conditions' above.)
●Symptoms associated with brain tumors – The features of brain tumor
headache are generally nonspecific and vary widely with tumor location,
size, and rate of growth. The headache is usually bilateral but can be on
the side of the tumor. Supratentorial tumors impinging on structures
innervated by the ophthalmic division of the trigeminal nerve may produce
a frontotemporal headache, while posterior fossa tumors compressing the
glossopharyngeal and vagus nerves can cause occipitonuchal pain. There
 is generally little radiation of pain, except in posterior fossa tumors.
Among children with headache who have brain tumors, additional
symptoms are almost always present at the time of diagnosis, and
funduscopic or neurologic examination is often abnormal. In addition to a
chronic progressive pattern, the following symptoms suggest the
possibility of an intracranial mass, such as a brain tumor (see "Brain tumor
headache", section on 'Clinical features'):
•Headache pain that wakes the patient from sleep or occurs on waking
in the morning
•Association with vomiting, especially progressive vomiting
•Behavioral changes
•Polydipsia/polyuria and/or visual field deficits (suggestive of
craniopharyngioma)
•Other neurologic symptoms, such as ataxia, change in coordination,
"clumsiness," blurred vision, or diplopia
●Trauma – Intracranial hemorrhage may cause headache for a child who
has had a head injury, although this history may be absent in cases of
abusive head trauma, especially in children younger than five years of
age. (See 'Subarachnoid and intracranial hemorrhage' above.)
●Environmental exposure – Abrupt onset of headache and nausea in
several members of one household (or headache and syncope in a child)
may be the result of carbon monoxide (CO) poisoning. (See 'Carbon
monoxide poisoning' above.)
●Change in visual acuity – Patients with idiopathic intracranial
hypertension (IIH) may report a deterioration in visual acuity along with
severe, unrelenting headache. (See "Elevated intracranial pressure (ICP)
in children: Clinical manifestations and diagnosis", section on 'Clinical
manifestations'.)
●Autonomic symptoms – Sweating or other autonomic symptoms may
accompany cluster headaches or malignant hypertension caused by a
pheochromocytoma. (See "Cluster headache: Epidemiology, clinical
features, and diagnosis", section on 'Clinical
features' and "Pheochromocytoma and paraganglioma in children",
section on 'Clinical presentation'.)
●Aura – Migraine headache, particularly in children over 10 years of age,
may involve an aura, such as scintillations or scotomata.
(See "Pathophysiology, clinical features, and diagnosis of migraine in
children", section on 'Clinical features'.)
Past medical history — In addition to children with immunodeficiencies or
ventriculoperitoneal shunts, headaches in those with the following conditions
may be life threatening (see 'Life-threatening conditions' above):
●Malignancy – Life-threatening conditions that can cause headache
among children with known malignancies include infection, hemorrhage,
and metastatic disease.
●Coagulopathy – Intracranial hemorrhage must always be considered as
a cause of headache for patients with coagulation defects, including those
with acquired coagulopathy (eg, immune thrombocytopenia, disseminated
intravascular coagulopathy) or taking anticoagulant medication.
●Sickle cell disease – Cerebrovascular accident is the leading cause of
death among children with sickle cell disease. Intracranial hemorrhage
 accounts for about one-third of these cerebrovascular events. (See "Acute
ischemic and hemorrhagic stroke in sickle cell disease".)
●Cyanotic heart disease – Headache may be the manifestation of brain
abscess caused by septic emboli among children with cyanotic heart
disease and a right-to-left intracardiac shunt who develop endocarditis.
(See "Pathogenesis, clinical manifestations, and diagnosis of brain
abscess".)
Physical examination — A complete physical examination should be
performed, including vital signs (with temperature and blood pressure [BP]
measurements) and a thorough neurologic examination.
●General appearance – Most children with serious causes for their
headaches are ill appearing or have altered mental status (eg, confused,
lethargic, or comatose).
●Vital signs – The vital signs must include temperature, heart rate, and
BP measurements. Fever suggests infection or, rarely, intracranial
hemorrhage. Elevated BP alone (table 9 and table 10) may result in
headache symptoms or may be a response to increased intracranial
pressure (ICP) along with bradycardia or, in children, tachycardia as part
of Cushing triad. (See "Elevated intracranial pressure (ICP) in children:
Clinical manifestations and diagnosis", section on 'Acutely elevated ICP'.)
●Head and neck – The head and neck should be examined for evidence
of trauma. Other findings on examination that may suggest a diagnosis
include:
•The diagnosis of otitis media can be determined with otoscopy.
(See "Acute otitis media in children: Clinical manifestations and
diagnosis", section on 'Diagnosis'.)
•Children with maxillary or frontal sinusitis may have facial tenderness
to palpation or purulent rhinorrhea.
•Streptococcal pharyngitis as a cause of headache may be evident
with swelling, erythema, and exudates of the tonsillar pillars.
Pharyngitis due to other etiologies may present with pharyngeal
enanthem, simple erythema, or erythema with exudates. (See "Group
A streptococcal tonsillopharyngitis in children and adolescents: Clinical
features and diagnosis", section on 'Clinical features' and "Evaluation
of sore throat in children", section on 'Common conditions'.)
•The teeth and gingiva should be examined for evidence of
inflammation or abscess.
•Tenderness over the temporomandibular joint (TMJ) and/or masseter
muscles suggests TMJ dysfunction.
•Nuchal rigidity can be a sign of migraine headache, meningitis,
intracranial hemorrhage, or, less commonly, brain tumor [37].
●Skin – Children with neurocutaneous syndromes (ie, neurofibromatosis
or tuberous sclerosis) may have brain lesions causing headaches. Skin
should be carefully examined for characteristic features, such as café au
lait spots or ash leaf spots [12]. (See "Tuberous sclerosis complex:
Genetics, clinical features, and diagnosis", section on 'Brain
lesions' and "Neurofibromatosis type 1 (NF1): Pathogenesis, clinical
features, and diagnosis", section on 'Clinical manifestations'.)
 Bruising characteristics that should raise concern for child abuse are
provided in the table and discussed in detail separately (table 11).
(See "Physical child abuse: Recognition".)
Neurologic examination — The majority of children with headaches who have
serious neurologic conditions have abnormalities on neurologic examination
[26,38,39]. The following findings are significant for children with headaches:
●Altered mental status may be the result of encephalitis, intracranial
hemorrhage, elevated ICP, or hypertensive encephalopathy. Seizures that
are focal or associated with a prolonged postictal period (but not including
febrile seizures) raise concern for an intracranial focus such as an
intracranial hemorrhage or brain tumor.
●Funduscopic examination should be performed for all children who are
being evaluated for headache. Adequate visualization of disks may be
challenging in young or uncooperative patients. Papilledema,
hemorrhages, exudates, and abnormal vessels are important
manifestations of serious intracranial pathology, but the absence of these
findings does not exclude significant conditions.
●Extraocular muscle palsies or nystagmus may be the result of elevated
ICP or direct compression by a mass lesion.  
●Motor asymmetry, gait disturbance, or difficulty with fine motor
coordination suggests a focal intracranial lesion.
●Some children with migraine headaches develop focal neurologic
abnormalities (eg, ophthalmoplegia, motor weakness, or ataxia) as part of
their migraine syndromes (table 5) [40]. Caretakers can generally confirm
that the pattern is typical for the child's headaches.
The elements of the pediatric neurologic examination are discussed in detail
separately. (See "Detailed neurologic assessment of infants and children",
section on 'Neurologic examination'.)
Ancillary studies — The need for ancillary studies is determined by the
patient's clinical findings. Patients with no red flag findings on history and a
normal neurologic examination should not undergo routine lab studies, lumbar
puncture, electroencephalography (EEG), or neuroimaging [27,38].
Neuroimaging
Indications — Indications and timing of neuroimaging are determined by
clinical findings:
●Red-flag findings – Patients at the highest risk for life-threatening
intracranial conditions and for whom we recommend emergency
neuroimaging include patients with any one of the following red-flag
findings [8,13,26,38,41,42]:
•Focal neurologic examination (eg, cranial nerve deficits, visual field
cuts, focal motor weakness, asymmetric reflexes, or focal seizure other
than seizures consistent with febrile seizures), prolonged altered
mental status (>60 minutes), ataxia, or dysmetria
•Papilledema or other signs of increased intracranial pressure (eg,
headache precipitated or worsening by a prolonged period of lying
down [especially when associated with vomiting], hypertension with
brady- or tachycardia, or progressive vomiting)
•Abrupt onset of "worst headache of life (“thunderclap” headache),
especially if associated with neck pain or stiffness
 ●Chronic, progressive headache and normal examination – In patients
with a chronic progressive headache but a normal neurologic examination
and no findings of intracranial hypertension, including a normal
funduscopic examination, we suggest either an emergency fast MRI, if
available, or an expedited outpatient MRI (within 24 to 48 hours) and
timely follow-up with their primary care provider or pediatric neurologist.
This approach avoids the radiation exposure of an emergency CT scan.
●Cutaneous findings – Patients with skin lesions suggestive of
neurocutaneous syndromes warrant prompt pediatric neurology
consultation and should receive MRI as part of a diagnostic evaluation.
(See "Tuberous sclerosis complex: Genetics, clinical features, and
diagnosis", section on 'Evaluation and diagnosis' and "Neurofibromatosis
type 1 (NF1): Pathogenesis, clinical features, and diagnosis".)
Children with a nontraumatic headache with no worrisome features, normal
funduscopy, and a normal neurologic examination have a low risk for a life-
threatening intracranial abnormality (<0.4 percent) and do not require imaging
[38].
Many experts regard certain headache characteristics and patient history as
worrisome and in need of further investigation by emergency neuroimaging
(table 12) [13,38,41]. However, most of these findings are nonspecific, and the
prevalence of life-threatening conditions in previously healthy patients with
these features is low. For example, in a prospective observational study of
almost 200 otherwise healthy children with one or more red-flag findings on
history, 73 underwent emergency imaging (either fast magnetic resonance
imaging [MRI] or computed tomography [CT]), and one patient had an
emergency intracranial abnormality (brain tumor) [13]. No emergency conditions
were identified in the patients who did not receive emergency imaging as
determined by follow-up at four to six months. (See 'MRI versus CT' below.)
MRI versus CT — For stable, previously healthy patients with a nontraumatic
headache who warrant emergency imaging, we suggest fast MRI whenever
available, as long as rapid pediatric radiology interpretation is assured [4,43].
This approach avoids significant radiation exposure. (See "Ischemic stroke in
children: Clinical presentation, evaluation, and diagnosis", section on 'CT safety
considerations'.)

In unstable patients, or if MRI with rapid interpretation is not available, CT of the

brain should be performed. CT does not require sedation in most children and
generally identifies any condition that requires immediate treatment. If a CT is
performed, some children may require a MRI at a later time to provide clearer
definition of abnormalities noted on CT or to identify lesions that may not be
seen on CT (eg, some infections, hemorrhagic processes, or cerebral venous
thrombosis).

Lumbar puncture — The emergency evaluation of a child with headache

should include a lumbar puncture (LP) in the following situations:
●Suspected nonfocal infection (meningitis, encephalitis)
●Concern for subarachnoid hemorrhage not diagnosed on neuroimaging
●To measure opening pressure for suspected idiopathic IIH (after
neuroimaging)
Patients with focal neurologic examinations, a change in level of consciousness,
significant concern for increased ICP, or papilledema should have an
emergency CT scan or fast MRI performed before LP. There is a risk of
herniation syndrome when LP is performed in patients with increased ICP and
an abnormal ICP gradient (eg, tumor or abscess with a midline shift, obstructive
hydrocephalus). (See "Lumbar puncture: Indications, contraindications,
technique, and complications in children", section on 'Cerebral herniation'.)
Antibiotic therapy should not be delayed for children with suspected meningitis
who are unstable or must receive neuroimaging before an LP is performed
(table 7). (See "Bacterial meningitis in the neonate: Clinical features and
diagnosis", section on 'Lumbar puncture'.)
The appropriate cerebrospinal fluid (CSF) studies to obtain include CSF cell
count and differential, glucose, protein, Gram stain, and bacterial culture. CSF
results in bacterial and viral infection are provided in the table (table 13).
Depending upon the clinical suspicion and patient presentation, the clinician
may also include specialized viral testing. (See "Viral meningitis in children:
Clinical features and diagnosis", section on 'Detection of virus'.)
Borrelia burgdorferi-specific antibodies can help establish the diagnosis of
central nervous system Lyme disease, but a negative test does not exclude it.
Blood testing for Lyme disease should also be performed. Lyme PCR has low
sensitivity, and false positives have been frequently reported. Thus, Lyme PCR
is not recommended for routine testing of CSF in Lyme disease. (See "Nervous
system Lyme disease", section on 'Meningitis'.)
Other studies — In patients whose history and/or physical examination
suggest a life-threatening etiology, other studies may be indicated depending
upon the suspected cause:
●A complete blood count, C-reactive protein, erythrocyte sedimentation
rate, electrolytes, serum glucose, blood urea nitrogen, serum creatinine,
and blood cultures are warranted for a child with possible bacterial
meningitis. (See "Bacterial meningitis in children older than one month:
Clinical features and diagnosis", section on 'Blood tests'.)
●In addition to testing as above for bacterial meningitis, patients with
possible viral meningitis may warrant serologic tests for specific
pathogens based upon clinical suspicion. (See "Viral meningitis in
children: Clinical features and diagnosis", section on 'Blood tests'.)
●An elevated carboxyhemoglobin by direct cooximetry on a venous or
arterial blood gas establishes the diagnosis of CO poisoning.
(See "Carbon monoxide poisoning", section on 'Diagnosis'.)
●Recommended studies for children with hypertensive emergencies are
provided in the table and discussed separately (table 14). (See "Approach
to hypertensive emergencies and urgencies in children", section on
'Ancillary studies'.)
●Patients who reside in or have visited an endemic area for Lyme, have a
risk factor for tick exposure, and have clinical findings consistent with
Lyme meningitis should undergo serologic testing for Lyme disease.
Diagnosis and treatment of Lyme meningitis differs from bacterial
meningitis in that CSF studies are not always necessary and oral antibiotic
therapy can be an appropriate treatment method. (See "Diagnosis of
Lyme disease", section on 'Serologic tests' and "Treatment of Lyme
disease", section on 'Acute neurologic manifestations'.)
 DIAGNOSTIC APPROACH A systematic approach to the

emergency evaluation of children with nontraumatic headaches (including a

focused history, careful physical examination, and selected ancillary studies)
generally identifies those who have conditions that require rapid diagnosis and
treatment (table 2 and algorithm 5A-B). Previously healthy children with no red-
flag findings on history and a normal neurologic examination
should not undergo routine lab studies, lumbar puncture,
electroencephalography (EEG), or neuroimaging [27,38].  
Children with headaches who are immunocompromised, have
ventriculoperitoneal shunts, or have been injured require specific evaluations
that frequently include ancillary studies, such as neuroimaging. (See "Severe
traumatic brain injury (TBI) in children: Initial evaluation and
management" and "Minor blunt head trauma in infants and young children (<2
years): Clinical features and evaluation" and "Hydrocephalus in children:
Management and prognosis", section on 'Shunt complications'.)
Chronic or recurrent headaches — For older children and adolescents who
present with typical headache patterns and no additional findings, the diagnosis
of migraine or tension headache can often be made following a careful history,
family history, and thorough physical examination [38]. Those with a change in
the headache pattern or new clinical features (eg, fever or stiff neck) may
require ancillary studies as directed by the history and physical examination.
Normal neurologic examination — Children with headache who have no
worrisome historical features (table 12) and normal neurologic examinations,
including funduscopic examination, generally do not require neuroimaging [38].
(See 'Neuroimaging' above.)
Fever — For children with headache, fever, and meningeal signs, cerebrospinal
fluid (CSF) evaluation for glucose and protein levels, cell count, and culture
should be performed. Central nervous system infection can usually be
diagnosed by CSF evaluation (table 13). (See "Bacterial meningitis in children
older than one month: Clinical features and diagnosis", section on
'Interpretation'.)
Children with normal CSF studies and those with headache and fever without
meningeal signs (who typically do not require CSF evaluation) likely have
infectious causes for headache, such as viral syndrome, sinusitis, or dental
abscess. (See 'Common conditions' above.)
No fever — A child with headache, a normal neurologic examination, and no
fever, who has no other abnormal features identified on history or physical
examination, may be experiencing a first migraine or a tension-type headache.
(See 'Common conditions' above.)

Clinical features identified by history or physical examination that suggest a

specific diagnosis include the following:

●Exposure to improperly vented home heating systems, space heaters, or

automobile exhaust fumes suggests carbon monoxide (CO) poisoning.
(See 'Carbon monoxide poisoning' above.)
 ●Hypertensive encephalopathy may be the cause of headache for children
with elevated blood pressure (BP) measurements (table 9 and table 10).
(See 'Hypertensive urgency or emergency' above.)
●Children with tenderness to palpation over sinuses, teeth, or
temporomandibular joints (TMJs) may have focal infections or TMJ
syndrome. (See 'Common conditions' above and 'Temporomandibular
joint dysfunction' above.)
Focal neurologic examination — The emergency evaluation of children with
headache who have focal findings on neurologic examination (including focal
seizures in afebrile children) or papilledema includes neuroimaging. Computed
tomography (CT) is readily available, requires no sedation, and generally
identifies any condition that requires emergency treatment. Thus, it is the
preferred imaging modality in unstable patients. Stable patients may undergo
CT or, if reliable interpretation is rapidly available, fast MRI. (See 'MRI versus
CT' above.)
Computed tomography abnormal — Conditions that cause headache and
focal neurologic findings that may be identified with CT include mass lesions
(eg, brain tumors, cerebral abscesses or hematomas), hydrocephalus, and
intracranial hemorrhage. Patients with abnormal CT scans require emergency
neurosurgical evaluation. (See 'Life-threatening conditions' above.)
Computed tomography normal — In patients who have normal head CTs,
lumbar puncture (LP) for CSF evaluation and opening pressure should be
performed for those patients with extremely severe headaches and/or neck
stiffness.

The following abnormalities suggest a specific diagnosis:

●Red blood cells in CSF (with a nontraumatic LP) may indicate

subarachnoid hemorrhage. (See 'Subarachnoid and intracranial
hemorrhage' above.)
●An elevated white blood cell count is consistent with central nervous
system inflammation, such as occurs with infection (table 13). In children
with focal neurological findings and CSF pleocytosis, herpes simplex virus
should be strongly considered, as some patients may benefit from
treatment with acyclovir. (See "Bacterial meningitis in children older than
one month: Clinical features and diagnosis", section on
'Interpretation' and "Herpes simplex virus type 1 encephalitis".)
●Children with papilledema, normal head CT scans, and elevated opening
pressures on LP may have idiopathic increased intracranial hypertension
(IIH). Rarely, patients with these findings have cerebral venous
thromboses. Magnetic resonance imaging (MRI) is required to distinguish
cerebral venous thrombosis from IIH. Consequently, children with
apparent IIH who are asymptomatic (except for headache) and are well
enough to be discharged from the emergency department (ED) should be
evaluated by a neurologist within the next several days. (See "Idiopathic
intracranial hypertension (pseudotumor cerebri): Clinical features and
diagnosis".)
●Patients with apparent papilledema who have normal CT scans, normal
CSF evaluations, and normal opening pressures on LP may have
pseudopapilledema with headaches from unrelated etiologies.
 (See "Overview and differential diagnosis of papilledema", section on
'Bilateral disc abnormalities'.)

A child with a moderately severe headache, no neck stiffness, focal neurologic

findings that have resolved, and a normal head CT may have a migraine with
aura.

The International Headache Society notes that aura associated with a migraine
headache typically lasts for less than 60 minutes. A patient with a new or
atypical headache and focal findings that last for longer than one hour may
have a more serious cause for headache. Children in this situation who are ill
appearing should undergo emergency MRI. Those whose symptoms have
improved and who look well may be scheduled for MRI as an outpatient within
several days. (See "Types of migraine and related syndromes in children",
section on 'Complications of migraine'.)

INFORMATION FOR PATIENTS UpToDate offers two types of

patient education materials, "The Basics" and "Beyond the Basics." The Basics
patient education pieces are written in plain language, at the 5 th to 6th grade
reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10 th to 12th grade reading level and are
best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Headaches in children (The

Basics)")

SUMMARY AND RECOMMENDATIONS

●Epidemiology – The majority of children who undergo emergency

evaluation for nontraumatic headaches have self-limited conditions such
as a minor febrile illness or a primary headache syndrome (table 5).
However, a significant minority of previously healthy patients have life-
threatening causes that require urgent diagnosis and treatment (table 2).
(See 'Epidemiology' above and 'Causes' above.)
●Stabilization – Rapid recognition and treatment of life-threatening
causes of nontraumatic headache in children is described in the following
algorithms and rapid overview tables:
•Intracranial hypertension (algorithm 1) (see "Elevated intracranial
pressure (ICP) in children: Management")
 •Bacterial meningitis (table 7) (see "Bacterial meningitis in children
older than one month: Treatment and prognosis")
•Carbon monoxide poisoning (table 8 and algorithm 2) (see "Carbon
monoxide poisoning")
•Hypertensive urgency or emergency (algorithm 3 and algorithm 4)
(see "Initial management of hypertensive emergencies and urgencies
in children")
●Evaluation – Once stabilized, a systematic approach to the emergency
evaluation of children with headaches generally identifies the underlying
cause (algorithm 5A-B). (See 'Diagnostic approach' above.)
•History – Nontraumatic headache characteristics that raise concern
for a life-threatening cause include any one of the following (table 12)
(see 'History' above):
-Abrupt onset that is very painful (thunderclap, "worst headache of
my life")
-Positional (ie, presents or worsens upon lying down)
-Awakens the child from sleep
-Occurs soon after awakening in the morning
-Precipitated or worsened by a Valsalva maneuver or exercise
-Chronic and progressive (ie, increased frequency and severity
over time)
-Associated with vomiting (especially progressive and/or morning
vomiting), behavioral changes, vision changes, polydipsia and
polyuria, clumsiness, and/or ataxia,
-Occurring in patients with shunted hydrocephalus, malignancy,
sickle cell disease, immunodeficiency, coagulopathy, or cyanotic
heart disease
•Physical examination – Concerning findings include any one of the
following (see 'Physical examination' above):
-Hypertension with brady- or tachycardia suggestive of increased
intracranial pressure (ICP)
-Prolonged altered mental status (>60 minutes)
-Papilledema
-Neck stiffness
-Ataxia or dysmetria
-Focal neurologic deficits
•Neuroimaging – Indications and timing of neuroimaging in previously
healthy children are determined by clinical findings
(see 'Indications' above):
-Red flag findings – For children with a focal neurologic
examination, findings of increased ICP, or "thunderclap" headache
(especially if associated with neck pain or stiffness), we
recommend stabilization, as needed, and emergency
neuroimaging. For stable, previously healthy patients, we suggest
fast magnetic resonance imaging (MRI) if rapid pediatric radiology
interpretation is assured. Unstable patients or patients for whom
 MRI with rapid interpretation is not available require brain
computed tomography (CT). (See 'MRI versus CT' above.)
-Chronic, progressive headache and normal examination – In
patients with chronic, progressive headache with a normal
physical examination, we suggest either an emergency fast MRI if
rapid pediatric radiology interpretation is assured, or an expedited
outpatient MRI (within 24 to 48 hours) followed by timely follow-up
with their primary care provider or pediatric neurologist.
-Cutaneous findings – Patients with skin lesions suggestive of
neurocutaneous syndromes warrant prompt pediatric neurology
consultation and should receive MRI as part of a diagnostic
evaluation.
•Lumbar puncture – The emergency evaluation of a child with
nontraumatic headache should include a lumbar puncture (LP) in the
following situations (see 'Lumbar puncture' above):
-Suspected nonfocal infection (meningitis, encephalitis)
-Concern for subarachnoid hemorrhage not diagnosed on
neuroimaging
-To measure opening pressure for suspected idiopathic
intracranial hypertension (IIH; after neuroimaging)
Patients with these indications and a focal neurologic examination,
significant concern for increased ICP, or papilledema should have
emergency neuroimaging performed before LP (table 7). Antimicrobial
therapy should not be delayed for children with suspected meningitis
who are unstable or must receive neuroimaging before an LP is
performed.
•Other studies – In previously healthy children whose history and/or
physical examination suggest a life-threatening etiology, other studies
may be indicated depending upon the suspected cause. (See 'Other
studies' above.)

ACKNOWLEDGMENT The UpToDate editorial staff acknowledges

Christopher King, MD, FACEP, now deceased, who contributed to an earlier

version of this topic review.