A 12-year-old boy has chronic headache that worsens during the school day. These headaches are not associated with nausea or emesis, and he does not have any symptoms prior to the headache.
- Tension headache
- Factitious headache
- Vascular headache (migraine)
- Increased intracranial pressure
- Hemiplegic migraine
Explanation
Headaches can be a concerning symptom in the pediatric population, especially to parents; it is a common pediatric complaint. Vascular headaches can occur in all ages, and patients usually have a family history of migraine. While the typical scotomata discussed in adult migraine is not normally associated in children with migraine, pediatric migraines may have a nonspecific prodrome consisting of a change in mood, temperament, or appetite. Worsening headaches with nausea and emesis (particularly early morning emesis) are concerning for increased intracranial pressure from a mass lesion. Other associated findings may be decreased school performance, behavioral changes, or focal neurologic deficits. Papilledema may be present. Imaging would be necessary with this presentation.
Tension headaches are common in the older child and adolescent. They will worsen during the day, and may worsen with stressful situations like tests. They are typically described as squeezing, but are not usually pulsatile. Nausea and vomiting are not typical.
Factitious headache, as with any factitious diagnosis, should be one of exclusion. Hemiplegic migraine is descriptive of a typical aura that involves unilateral sensory or motor signs with a migraine headache. Patients can have unilateral weakness, numbness, and aphasia. These signs may resolve quickly or may last for days. This particular type of migraine is more common in children than in adults.