Young children cannot describe a headache, so the red flags are behaviour, growth of the head, and the neurological examination; in the older child the history does the work.
8 months
Raised intracranial pressure and meningitis, presenting as irritability, vomiting and a full fontanelle.
Differential
- Meningitis
- Hydrocephalus
- Non-accidental head injury (subdural hemorrhage)
- Brain tumour
- Otitis media
What changes
Measure and plot the head circumference. Feel the fontanelle when the infant is calm and upright. Examine for retinal hemorrhages if there is any concern about injury. A bulging fontanelle with fever is a lumbar puncture question after the pressure question is answered.
4 years
The posterior fossa tumour that presents with morning vomiting and ataxia.
Differential
- Viral illness with headache
- Migraine (family history, pallor, vomiting, sleep relieves)
- Brain tumour (morning headache, vomiting, ataxia, new squint, head tilt)
- Sinusitis
- Meningitis
What changes
Ask about the time of day, vomiting without nausea, changes in gait or vision, and behaviour. Examine the fundi, the cranial nerves, the gait and the coordination. Any focal sign or morning pattern is imaging.
10 years
Migraine is common and manageable; the red flags are still the tumour and the pressure.
Differential
- Migraine
- Tension-type headache
- Medication overuse headache
- Idiopathic intracranial hypertension (obesity, papilledema)
- Brain tumour
- Sinusitis
What changes
A headache diary, the triggers, the effect of sleep. Fundoscopy is the examination that must not be skipped. Reassure when the examination is normal and the pattern is typical; image when it is not.
16 years
Adult secondary headaches, and the psychosocial context that drives many adolescent headaches.
Differential
- Migraine
- Tension-type headache
- Idiopathic intracranial hypertension
- Subarachnoid hemorrhage or arterial dissection (thunderclap, trauma)
- Substance use and withdrawal (caffeine, cannabis)
- Sleep deprivation, screen use, mood
What changes
Ask about sleep, screens, stress, substances and mood, privately. A thunderclap onset or a neurological sign gets adult-style imaging.