Life-Threatening Secondary Headaches in Children: Management in the ED

An Evidence-Based Review of Life-Threatening Secondary Headaches in Pediatric Patients in the Emergency Department (Stroke CME and Pharmacology CME)

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Table of Contents

About This Issue

Diagnosis of life-threatening etiologies of headache in pediatric patients can be difficult. It is important to obtain a careful history, perform a thorough examination, and keep a broad differential diagnosis. This issue reviews the pathophysiology, signs and symptoms, and initial workup and management of life-threatening causes of pediatric headaches. In this issue, you will learn:

The most common causes of acute secondary headaches

Clinical presentations of the most common etiologies of life-threatening secondary headaches in pediatric patients

Key questions to ask while obtaining the history, including questions regarding the headache pattern, location, and pain quality and severity; exacerbating or relieving factors; and red-flag signs and symptoms

Guidance for performing a thorough physical examination, including a general examination, skin examination, and neurological examination

When imaging is warranted in children presenting with acute headache

Recommendations for the workup and initial management of vascular etiologies, intracranial infections, extracranial infections, space-occupying lesions, and increased intracranial pressure

Special considerations for patients with cerebrospinal fluid shunts, those with hemoglobinopathies or coagulopathies, immunocompromised patients, hypertensive patients, and patients with environmental exposures

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
  7. Differential Diagnosis
    1. Vascular Etiologies
    2. Intracranial Infections
    3. Extracranial Infections
    4. Space-Occupying Lesions and Increased Intracranial Pressure
  8. Prehospital Care
  9. Emergency Department Evaluation and General Approach
    1. History
      1. Patient-Specific History
      2. Headache Pattern
      3. Headache Location
      4. Headache Pain Quality and Severity
      5. Exacerbating or Relieving Factors
      6. Additional Signs and Symptoms
    2. Physical Examination
      1. General Examination
      2. Neurologic Examination
  10. Diagnostic Studies
    1. Imaging Studies
  11. Management, by Etiology
    1. Vascular Etiologies
      1. Workup
      2. Initial Treatments
    2. Intracranial Infections
      1. Workup
      2. Initial Treatments
    3. Extracranial Infections
      1. Workup
      2. Initial Treatments
    4. Space-Occupying Lesions and Increased Intracranial Pressure
      1. Workup
      2. Initial Treatments
  12. Special Populations
    1. Patients With Cerebrospinal Fluid Shunts
    2. Patients With Hemoglobinopathies or Coagulopathies
    3. Immunocompromised Patients
    4. Hypertensive Patients
    5. Patients With Environmental Exposures
  13. Controversies and Cutting Edge
    1. Hypertonic Saline Versus Mannitol for Lowering Intracranial Pressure
    2. Evaluation of Childhood Stroke
    3. Risk-Stratification Model
  14. 5 Things That Will Change Your Practice
  15. Risk Management Pitfalls for Pediatric Patients With Headache
  16. Disposition
  17. Summary
  18. Time- and Cost-Effective Strategies
  19. Case Conclusions
  20. Clinical Pathway for Suspected Life-threatening Causes of Headache
  21. Tables and Figures
  22. References


Headache is a common complaint in pediatric patients presenting to the emergency department. Diagnosis of life-threatening pathology can be difficult due to the nonspecific symptoms for many of these conditions. Emergency clinicians must have a high index of suspicion, obtain a detailed history, and conduct a thorough physical examination to accurately identify life-threatening causes of headache. This issue reviews the general approach, differential diagnosis, and initial workup and management of the most common dangerous causes of secondary headaches in pediatric patients.

Case Presentations

A 4-year-old previously healthy girl is brought into the emergency department by her mother for 6 days of vomiting and headache...
  • The child has woken up several times over the last week holding her head, crying, and vomiting nonbloody, nonbilious emesis. The girl’s brother is sick with viral gastroenteritis; however, the mother says the girl has not had diarrhea or fever.
  • The girl’s vital signs are: temperature, 37°C; heart rate, 69 beats/min; respiratory rate, 30 breaths/min; and blood pressure, 120/64 mm Hg.
  • Your examination is notable for truncal instability when the child attempts to sit up.
  • What is the next step in your workup?
Your next patient is a 17-year-old girl with sickle cell HbSS who presents with a headache...
  • The girl describes the headache as being in the back of her head, with sharp, intermittent pain, and she has blurry vision in both eyes. She denies fever, cough, chest pain, or shortness of breath.
  • What could be causing the girl’s headache? How does the history of sickle cell anemia inform your differential diagnosis and workup?

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Clinical Pathway for Suspected Life-threatening Causes of Headache

Clinical Pathway for Suspected Life-threatening Causes of Headache

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Tables and Figures

Table 2. Types of Imaging, Indications, Benefits, and Disadvantages

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Conicella E, Raucci U, Vanacore N, et al. The child with headache in a pediatric emergency department. 2008;48(7):1005-1011. (Retrospective chart review; 432 patients) DOI: 10.1111/j.1526-4610.2007.01052.x

4. * Hsiao HJ, Huang JL, Hsia SH, et al. Headache in the pediatric emergency service: a medical center experience. Pediatr Neonatol. 2014;55(3):208-212. (Retrospective chart review; 409 patients) DOI: 10.1016/j.Pedneo.2013.09.008

6. * Güngör A, Göktuğ A, Bodur İ, et al. Retrospective evaluation of acute headache in pediatric emergency department: etiologies, red flags, and neuroimaging. Neurologist. 2022;27(3):95-99. (Retrospective study; 558 patients) DOI: 10.1097/nrl.0000000000000377

19. * Ferriero DM, Fullerton HJ, Bernard TJ, et al. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019;50(3):E51-E96. (Scientific statement) DOI: 10.1161/STR.0000000000000183

39. * Chu TPC, Shah A, Walker D, et al. Pattern of symptoms and signs of primary intracranial tumours in children and young adults: a record linkage study. Arch Disease Child. 2015;100(12):1115-1122. (Retrospective study; 4140 patients) DOI: 10.1136/archdischild-2014-307578

55. * Expert Panel on Pediatric Imaging, Hayes LL, Palasis S, et al. ACR Appropriateness Criteria® Headache-Child. J Am Coll Radiol. 2018;15(5S):S78-S90. (Evidence-based guideline) DOI: 10.1016/j.jacr.2018.03.017

56. * Luque M, Stambo GW. The use of rapid sequence magnetic resonance imaging of the brain as a screening tool for the detection of gross intracranial pathology in children presenting to the emergency department with a chief complaint of persistent or recurrent headaches. Pediatr Emerg Care. 2021;37(10):e660-e663. (Prospective cohort study; 105 patients) DOI: 10.1097/pec.0000000000002089

58. * Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284. (Practice guidelines) DOI: 10.1086/425368

62. * Kochanek PM, Adelson PD, Rosario BL, et al. Comparison of intracranial pressure measurements before and after hypertonic saline or mannitol treatment in children with severe traumatic brain injury. JAMA Netw Open. 2022;5(3):e220891. (Comparative effectiveness study; 1000 patients) DOI: 10.1001/jamanetworkopen.2022.0891

69. * Tsze DS, Ochs JB, Gonzalez AE, et al. Red flag findings in children with headaches: prevalence and association with emergency department neuroimaging. Cephalalgia. 2019;39(2):185-196. (Prospective cohort study; 224 patients) DOI: 10.1177/0333102418781814

Subscribe to get the full list of 70 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: headache, pediatric headache, primary headache, secondary headache, life-threatening headache, vascular etiologies of headache, intracranial infections, hemorrhagic headache, intracerebral hemorrhage, intracranial pressure, stoke, childhood stroke, pediatric stroke, ischemic stroke, posterior reversible encephalopathy syndrome, PRES, extracranial infections, Pott puffy tumor, cerebral venous thrombosis, CVT, space-occupying lesions, idiopathic intracranial hypertension

Publication Information

Sarah Chen, MD; Aarti Gaglani, MD; Michael J. Stoner, MD

Peer Reviewed By

Sujit Iyer, MD, FAAP; Emily Rose, MD, FAAP, FACEP

Publication Date

May 1, 2023

CME Expiration Date

May 1, 2026    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1 Stroke CME credit and 1 Pharmacology CME credit, subject to your state and institutional approval.

Pub Med ID: 37079903

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