What is the appropriate evaluation and management for a child presenting with fever and headache?

Evaluation and Management of Fever and Headache in Children

A child presenting with fever and headache requires urgent evaluation to exclude bacterial meningitis or other serious CNS infections, as these conditions can be life-threatening and only 58% of children with bacteremia or bacterial meningitis appear clinically ill. 1

Immediate Red-Flag Assessment

The following clinical features mandate urgent investigation and should never be dismissed:

• Fever with headache and vomiting represents the classic triad of CNS infection and requires immediate evaluation 1, 2, 3
• Altered mental status, confusion, or behavioral changes strongly suggest meningitis or encephalitis 1, 4
• Nuchal rigidity or photophobia are classic signs of meningeal irritation 1, 2
• Focal neurological deficits (weakness, cranial nerve palsy, visual disturbances) point toward stroke, abscess, or tumor 1, 2, 4
• Seizures in the febrile child require exclusion of meningitis, though most febrile seizures are benign 5

Critical caveat: The absence of classic signs does NOT exclude meningitis—characteristic clinical signs may be absent, particularly in young children 1, 6. In children beyond the neonatal period, the most common presentations are fever, headache, neck stiffness, and vomiting, but no single sign is present in all patients 1.

Age-Specific Risk Stratification

• Infants younger than 3 months have the highest risk of serious bacterial infection due to immature immune systems and require the most aggressive evaluation 1, 7
• Children younger than 6 years have higher risk of serious intracranial pathology 4
• Well-appearing status is unreliable: Only 58% of children with bacteremia or bacterial meningitis appear clinically ill 1

Immediate Laboratory Work-Up

Obtain these studies BEFORE initiating antibiotics:

• Blood cultures (essential for identifying bacteremia) 2, 4
• Complete blood count with differential 2, 4
• Hepatic transaminases and serum sodium 2, 4

Do NOT delay empiric antibiotics while awaiting laboratory results if the child appears toxic, has altered mental status, nuchal rigidity, or focal deficits 2, 4, 3.

Neuroimaging Strategy

First-Line Modality

MRI of the brain with and without IV contrast is the preferred initial study for suspected CNS infection because it provides superior detection of:

• Meningeal enhancement 1, 2, 3
• Encephalitis 1, 3
• Brain abscess 1, 2, 3
• Subdural or epidural empyema 1

Technical advantages: T2-FLAIR sequences identify vasogenic edema; diffusion-weighted imaging (DWI) detects cytotoxic edema; post-contrast T1-FLAIR demonstrates meningeal enhancement 1, 4, 3.

When MRI Is Unavailable

Non-contrast CT head provides 98% sensitivity for acute subarachnoid hemorrhage and rapidly identifies hydrocephalus, mass effect, or large abscesses 1, 4, 3.

If infection is strongly suspected and MRI cannot be obtained promptly, CT with IV contrast should be performed to evaluate for enhancing infectious collections 1.

Critical pitfall: A negative non-contrast CT should NOT conclude the evaluation for suspected encephalitis—26 children in one study had normal acute CT but abnormal MRI findings within 2 days 1.

Lumbar Puncture Guidance

DEFER lumbar puncture until AFTER neuroimaging if any of the following are present:

• Focal neurological deficits 2, 4
• Altered consciousness 2, 4
• Papilledema 2, 4
• Any concern for increased intracranial pressure 2, 4

Performing LP in these settings carries significant risk of brain herniation 2, 4.

For infants 1-3 months old with fever, cerebrospinal fluid should be obtained to identify patients at risk for meningitis, unless contraindications exist 1.

Empiric Antimicrobial Therapy

Do NOT delay empiric IV antibiotics while awaiting imaging or lumbar puncture if the child is unstable or appears ill 2, 4, 3.

Recommended Regimen:

• Age-appropriate broad-spectrum coverage: Ceftriaxone PLUS vancomycin 2, 4
• ADD IV acyclovir when encephalitis is suspected (altered mental status, seizures, focal deficits) 2, 4, 3
• Supportive care: IV anti-emetics and isotonic fluid resuscitation 2, 4

Differential Diagnosis (Prioritized by Mortality Risk)

Tier 1: Life-Threatening (Immediate Action Required)

• Bacterial meningitis/encephalitis: Classic fever-headache-vomiting presentation; altered mental status confirms high suspicion 1, 2, 3
• Brain abscess or subdural/epidural empyema: Often follows sinusitis or otitis media; presents with fever and recurrent headaches 1, 2, 3
• Intracranial hemorrhage: Thunderclap headache with vomiting; CT has 98% sensitivity 4, 3
• Acute hydrocephalus: Intermittent increased intracranial pressure manifests as recurrent headaches with vomiting 2, 4

Tier 2: Serious but Less Immediate

• Cerebral venous sinus thrombosis: Can cause recurrent headaches; requires dedicated MRV for detection (may be missed on routine MRI) 1, 2, 4
• Posterior fossa tumor: Progressive headaches and vomiting over months; fever atypical unless secondary infection 2, 4
• Acute disseminated encephalomyelitis (ADEM): Follows viral infection or vaccination; encephalopathy, fever; MRI shows large confluent T2 lesions 4, 3

Tier 3: Less Urgent

• Recurrent sinusitis: May produce repeated headaches; non-contrast CT of paranasal sinuses indicated when this is the dominant feature 1
• Serious viral infections: Respiratory syncytial virus, enterovirus, influenza, herpes simplex virus-1 can cause severe illness requiring ICU admission 8
• Migraine variant: Recurrent pattern fits migraine, but fever should prompt evaluation for secondary causes 2, 4

Disposition Criteria

Admit Immediately If:

• Any red-flag features present (fever with headache, altered mental status, focal deficits) 2, 4
• Neuroimaging reveals abnormal findings (meningeal enhancement, abscess, hydrocephalus) 2, 4
• CNS infection clinically suspected, even before definitive imaging 2, 4
• Child appears toxic or ill 1, 7

May Consider Discharge Only If:

• No red flags present
• Neurological examination completely normal
• Imaging (if performed) unremarkable
• Clinical picture fits benign etiology
• Reliable outpatient follow-up available 4

Critical Pitfalls to Avoid

• A normal initial MRI does NOT exclude cerebral venous sinus thrombosis—dedicated MRV is required when suspicion persists 1, 2, 4
• Never attribute fever to simple viral illness without first ruling out CNS infection in a child with headache 2
• Well-appearing status is unreliable—serious infections occur in well-appearing children 1
• Never perform lumbar puncture before imaging when focal signs, altered consciousness, or papilledema are present due to herniation risk 2, 4
• Antipyretic use in the previous 4 hours may mask fever at presentation 1
• The presence of a viral infection does not preclude coexistence of bacterial infection 1
• Bulging fontanelle has very low sensitivity (10%) and specificity for bacterial meningitis—routine LP based solely on this finding should be reconsidered 9