Emergency Department Workup for 10-Year-Old with Severe Frontal Headache
The appropriate workup for a 10-year-old with severe frontal headache in the emergency department should include non-contrast head CT if concerning features are present, followed by targeted treatment based on the underlying cause. 1
Initial Assessment
Red Flags Requiring Immediate Neuroimaging
- Severe headache with worsening symptoms
- Headache that wakes the child from sleep
- Headache with focal neurological deficits
- Headache with vomiting
- Headache with altered mental status
- Headache with seizures
- "Worst headache of life" description
Physical Examination Focus
- Vital signs including blood pressure
- Complete neurological examination
- Fundoscopic examination for papilledema
- Assessment of neck stiffness
- Evaluation for signs of trauma
Diagnostic Imaging Algorithm
When to Obtain Head CT
Head CT without contrast is indicated when:
- Severe headache with worsening symptoms
- Headache associated with other risk factors
- Thunderclap headache presentation
- Signs of increased intracranial pressure
The American College of Radiology recommends CT as the initial imaging modality in emergency settings due to its speed and sensitivity for detecting acute blood products 1.
When to Consider MRI
MRI with and without contrast is preferred when:
- No immediate life-threatening condition is suspected
- Evaluation of posterior fossa pathology is needed
- Assessment for demyelinating disease is warranted
- Time permits a more detailed evaluation
Laboratory Testing
- Complete blood count
- Basic metabolic panel
- Consider inflammatory markers (ESR, CRP) if infection suspected
- Consider lumbar puncture if meningitis/encephalitis is suspected and neuroimaging shows no contraindications
Management Based on Etiology
Primary Headache Treatment
- Provide nonopioid analgesia (ibuprofen or acetaminophen) 1
- Ensure adequate hydration
- Place in quiet, dark environment
- Avoid opioids as they are not generally recommended for headache therapy 1
Secondary Headache Management
- Target underlying cause
- For traumatic etiology: follow mild traumatic brain injury protocols
- For infectious etiology: appropriate antimicrobials
- For intracranial pathology: neurosurgical consultation as needed
Special Considerations for Pediatric Patients
Imaging Considerations
- Minimize radiation exposure when possible
- CT should not be delayed if MRI is not available or feasible in emergent situations 1
- Consider sedation needs for younger children undergoing MRI
Treatment Considerations
- Weight-based dosing for medications
- Counsel family regarding risks of analgesic overuse 1
- Consider multidisciplinary evaluation for chronic headaches 1
Follow-Up Recommendations
- Provide clear follow-up instructions
- Consider referral to pediatric neurology for recurrent headaches
- Educate on headache diary use for tracking frequency and triggers
Pitfalls to Avoid
- Failing to recognize "red flags" requiring urgent neuroimaging
- Overreliance on normal neurological examination to exclude serious pathology
- Inappropriate use of opioids for headache management
- Neglecting to consider age-specific etiologies (e.g., sinusitis, vision problems)
- Inadequate follow-up planning for recurrent headaches
By following this structured approach, clinicians can effectively evaluate and manage severe frontal headache in pediatric patients presenting to the emergency department, ensuring appropriate identification of life-threatening conditions while providing effective symptomatic relief.