SYMPOSIUM ON PGIMER PROTOCOLS IN NEUROLOGICAL EMERGENCIES Approach to Headache in Emergency Department Karthi Nallasamy & Sunit C. Singhi & Pratibha Singhi Received: 21 July 2011 /Accepted: 27 September 2011 /Published online: 20 October 2011 # Dr. K C Chaudhuri Foundation 2011 Abstract Headache remains a frequently encountered neurological symptom in Emergency department. Sec- ondary causes of headache outnumber the primary entities such as migraine. Most of the secondary headaches have benign etiologies. The goal of emergent evaluation is to detect those with serious or life threatening causes. Identifying the pattern of headache helps in narrowing down the possible etiological diagnosis. A single episode of acute headache usually results from an acute infection ranging from viral URI to acute meningitis. Acute recurrent headaches are typically a feature of migraine. Chronic progressive headaches often indicate a serious underlying pathology such as a brain tumor and warrant a detailed neurolog- ical examination for signs of raised intracranial pressure (ICP) and focal deficits. Children with abnormal neurological findings require a neuroimaging. CT scan usually detects most of the abnormalities. Initial stabi- lization and management of raised ICP takes precedence in sick children. While simple analgesics like para- cetamol and ibuprofen are used for symptomatic therapy, identification and appropriate treatment of underlying conditions is necessary for complete resolu- tion of headache. Keywords Children . Headache . Migraine . Brain tumor . Neuroimaging . Analgesics Introduction Headache is one of the most frequent neurological symptoms and about 60–70% children experience a headache by the age of 7 to 9 y. However, headache as an isolated symptom presenting to Emergency department (ED) is less common; it is often accompanied by other symptoms of an underlying illness. Children with acute or acute on chronic headaches are the most frequent visitors to emergency department while those with chronic headache are usually seen in outpatient department. Pathophysiology Headache is a result of referred pain from parts of the head and neck which include intracranial structures like the dura, large arteries, venous sinuses and extracranial structures like the periosteum, orbit, sinus, middle ear, teeth and facial muscles. Pathology in the brain parenchyma alone cannot cause headache as there are no pain receptors in it. Common Causes Headaches can be caused by primary entities as in migraine or tension-type headaches or the pain may result from secondary causes. Secondary headaches usually have identifiable etiologies. Although the vast majority of secondary headaches in children have benign underlying cause (such as viral infections), the goal of the emergent evaluation of children with headaches is to identify as a first priority those with serious or life-threatening etiology (brain tumors, CNS infections). Indian J Pediatr (March 2012) 79(3):376–380 DOI 10.1007/s12098-011-0570-2 K. Nallasamy : S. C. Singhi (*) : P. Singhi Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, (PGIMER), Chandigarh 160012, India e-mail: sunit.singhi@gmail.com