Evan Sherman MD, Children’s National Health System
Eiman Abdulrahman MD, Children’s National Health System

The Case
This is a case of a 5 year old with a headache and blurry vision. The patient’s young age made it difficult to evaluate his symptoms, and a few troubling aspects of the history prevented the clinician from effectively ruling out dangerous or life-threatening conditions.

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Denouement
The clinician discussed his concerns regarding the patient’s symptoms as well as the risks of a head CT. The parents were offered the option of performing a head CT now or returning to the ED in 2 days if the patient’s symptoms persisted. The parents decided to wait to see if the patient’s symptoms improved. The patient did not return to the ED. The clinician called the family the following week and spoke to the patient’s mother, who stated that the patient hadn’t complained of any pain since coming home from the ED and hadn’t developed any new symptoms. She also volunteered that she was encouraging him to wear his glasses more often.

Headache is a common chief complaint in the pediatric ED, but differentiating dangerous, life-threatening conditions from primary and non-life-threatening secondary headaches can be challenging. This is especially true in younger children who cannot provide a reliable history. Several studies on pediatric ED patients have attempted to determine the incidence of serious underlying pathology in pediatric headache patients, as well as identify “red flag” symptoms that warrant further workup. As an example, one study from Italy of ~400 patients found that 4% of pediatric patients who presented with a chief complaint of headache had a “dangerous” condition (these included viral meningitis, brain tumors, and VP shunt malfunction). Factors that were significantly associated with dangerous pathology included age less than 6 years, pain localized to the occipital region, “very intense” pain, and neurological signs (specifically, focal deficits, papilloedema, ataxia, or disturbances in consciousness). Notably absent was vomiting, which was a common symptom in both benign and life-threatening conditions.