John E. Monaco, M.D.
All in all, headache is a somewhat unusual complaint for children. Obviously, adolescents experience headache more commonly than younger children. In fact if a toddler complains of headache it should almost always be investigated.
Recently, in our inpatient pediatric service, we had three children seen for their headaches. One was a three year old, one 13 and the last was 17. All three exemplify why headache should not routinely be passed off as "tension" or even dehydration. Sometimes, there is something more serious behind this innocent sounding complaint.
Derek is a 3-year-old otherwise healthy participant in a busy day care program. His mother was called to pick him up one day because he was complaining of headache, nothing more. It was not until several hours later that he developed fever and vomiting prompting her to take him to the emergency room.
This set of symptoms persuaded the ER physician to perform a spinal tap. Derek's spinal fluid demonstrated a mild elevation in the number white blood cells with no bacteria found.
These findings are consistent with the diagnosis of aseptic (non-bacterial) meningitis. The most likely infective organism is a virus, typically the enteroviruses, but other viruses such as Herpes, can be the cause.
In general there is no specific treatment for viral meningitis, but IV fluids and occasionally a short course of steroids help reduce the inflammation contributing to the pressure which creates the headache. The point to Derek's story is that when a 3 year old complains of headache, unless he is mimicking an adult, it must be investigated.
The 13 year old, Jose, also had aseptic meningitis that was properly treated. He was readmitted several days after discharge from the hospital when his headache came back.
His mother reported that soon after discharge, his headache reoccurred and was severe enough to keep him out of school and to severely limit his appetite. We thought that his headache probably represented slow recovery from his meningitis, but we were not sure.
His mother was strongly against another spinal tap unless it was absolutely necessary. He did not have a fever and his blood work did not indicate any ongoing infection, so we felt it was permissible to hold off on the spinal tap pending other work-up.
An MRI of his brain was carried out to check for an abscess, a tumor or other causes of increased intracranial pressure that might result in headache. This study, fortunately, was negative. Again, with IV fluids and a short course of steroids, Jose's headache disappeared after 36 hours in the hospital, leaving us confident with our diagnosis of resolving meningitis.
Our third patient, Adam, did not have an infectious cause of his headache. He is a star high school football player who, while bench pressing nearly 200 pounds during his regular workout, experienced excruciating pain at the back of his head and down his neck. The pain was so severe that he slumped to his knees and became dizzy causing his coach to become quite worried about him.
He was rushed to the hospital where the ER doctor and neurologist suspected a ruptured aneurysm or some other cause for intracranial bleeding. An angiogram (a test where dye is injected into an artery and x-rays are taken) was performed. This is an unusual occurrence in pediatrics. The results were normal Ð the blood vessels of Adam's central nervous system were normal.
Relieved that Adam had not suffered a life threatening event, Adam's parents remained worried as to the cause of the headache. After further work-up, the neurologist diagnosed "exertional migraines." It turned out that he had experienced similar headaches during several practices. Anti-migraine medicines were prescribed and Adam's football career did not necessarily need to be over. But he and his family now knew that the impact associated with football could exacerbate his condition. Perhaps treatment would allleviate his headaches, but only time would tell.
We adults have headaches all the time. With our busy schedules and computer screens, tension headaches are probably more common than they ever were.
When children, especially young children, under school age, complain of their head hurting, it must be taken seriously. Kids, unlike adolescents and adults who are more likely to get migraines or tension headaches, don't have the kind of everyday headaches that older folks have. When a three year old says their head hurts, and they are not mimicking adult behavior they have seen, the possibility of a tumor should be considered, and will probably be worked up with a CT scan or MRI. This is definitely true if the headache is associated with other symptoms of an intracranial mass like vomiting or visual or neurologic changes.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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