Paeds · neurology-neurodisability-and-neuromuscular
Secondary headache and raised intracranial pressure
Also known as Secondary headache in a child · Raised intracranial pressure in childhood · Papilloedema and the dangerous headache · Idiopathic intracranial hypertension in children · Brain tumour headache · Pseudotumour cerebri syndrome
Fellowship guide to the child whose headache may be secondary: the central task is not to diagnose the headache but to exclude a dangerous cause, using a red-flag screen that separates the small minority with raised intracranial pressure from the large majority with a benign primary headache. The two syndromes that dominate the exam are idiopathic intracranial hypertension, defined by the Friedman 2013 revised criteria of papilloedema with normal neuroimaging and cerebrospinal fluid and an elevated opening pressure, and the brain tumour, whose HeadSmart symptom cluster of morning headache, vomiting and behavioural change is the key to early diagnosis. The single error that fails children is reassuring a progressive or morning headache with vomiting, because headache alone is a late and unreliable sign of a tumour.
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- A progressive, accelerating, or new-pattern headache is a secondary headache until imaging proves otherwise, especially when it is worse in the morning, wakes the child from sleep, or worsens with cough, straining or bending. This pattern points to raised intracranial pressure from a tumour or hydrocephalus and warrants urgent magnetic resonance imaging rather than a trial of analgesia.
- Papilloedema on fundoscopy is objective evidence of raised intracranial pressure and is the pivot of the whole assessment. Any child with headache and papilloedema needs urgent imaging and, once a mass is excluded, a lumbar puncture with an opening pressure. Never reassure a child whose optic discs are swollen.
- A thunderclap headache that reaches maximum intensity within a minute is a vascular emergency until proved otherwise. It raises intracranial haemorrhage, arterial dissection and cerebral venous sinus thrombosis, and it needs immediate imaging rather than a migraine label.
- A headache with a focal neurological deficit, an altered conscious level, ataxia, or a new squint demands imaging on the same day. These are the examination findings with the highest yield for intracranial pathology, and their absence does not make a progressive headache safe.
- The infant with raised intracranial pressure rarely complains of headache. A bulging or tense fontanelle, an increasing head circumference, vomiting, irritability and a downward sunset gaze are the infant equivalents, and the threshold for imaging is lower because the open sutures may mask the pressure.
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- Headache in a child
- Raised intracranial pressure and papilloedema
- Secondary headache and the red-flag assessment
- Idiopathic intracranial hypertension in children
- Secondary headache and raised intracranial pressure
- Child with a progressive or morning headache
- Brain tumour and the HeadSmart symptom cluster
- Short case: papilloedema and the fundoscopic examination
- Long case: adolescent with idiopathic intracranial hypertension
- Neurology: headache and raised intracranial pressure
- Late presentation of serious disease and the diagnostic interval
- Secondary causes of headache in children
- Idiopathic intracranial hypertension: criteria and management
- Neurological assessment: the child with headache and papilloedema
- Headache evaluation and red flags
- Increased intracranial pressure
- Patient Care: neurological conditions and raised intracranial pressure
- Medical Expert: secondary headache and raised intracranial pressure in children
This page is built around the three questions a clinician actually answers, in order, when a child presents with headache. First, is this a primary headache that is safe to manage in the community, or does a red flag demand imaging? Second, if imaging is needed, what modality and what finding? Third, for the two raised-pressure syndromes that examiners test hardest, how is idiopathic intracranial hypertension confirmed and treated, and how is a brain tumour recognised early? The thread that runs through all three is papilloedema: the fundoscopic finding that converts a subjective complaint into an objective sign of raised pressure. [6]
Headache is one of the commonest reasons a child is brought to a clinician, and the great majority are primary headaches that need no scan. The danger lies in the small secondary minority, where the cost of reassurance is a delayed tumour diagnosis, permanent visual loss, or death from herniation. The sections that follow teach the screen, mechanism, work-up, and the management of the raised-pressure syndromes, and they link to the headache-and-migraine leaf for primary headache depth and to the hydrocephalus-and-shunt-emergencies leaf for the mechanical and shunt-dependent pathways. [2] [10]
Overview & Definition
A secondary headache is a headache caused by a separate, identifiable process acting on the pain-sensitive structures of the head. The process may be a growing tumour, obstructed cerebrospinal fluid, an infection, a bleed, a vascular lesion, or a drug. A primary headache, by contrast, is the condition itself: migraine, tension-type headache, and the trigeminal autonomic cephalalgias are disorders of headache generation rather than symptoms of something else. [3]
The clinical problem is one of proportion. Most children with headache have a primary headache or a viral illness, and scanning every child would do more harm than good. Yet the secondary causes, though uncommon, carry the full weight of missed serious disease. The red-flag screen exists to resolve this tension: it tells the clinician when a headache has crossed the line from safe to investigate. [4]
Within the secondary headaches, the raised-intracranial-pressure syndromes are the exam centrepiece because they are common enough to meet, dangerous enough to matter, and treatable if found early. Idiopathic intracranial hypertension produces headache and papilloedema without a mass. A brain tumour produces headache and vomiting through a mass or through obstructed cerebrospinal fluid. Both can threaten vision or life, and both are missed when the clinician reaches for a reassuring label before examining the fundi. [8]
References12ShowHide
- [1]Lewis DW; Ashwal S; Dahl G; et al Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society Neurology, 2002.PMID 12196640
- [2]Langdon R; DiSabella MT Pediatric Headache: An Overview Curr Probl Pediatr Adolesc Health Care, 2017.PMID 28366491
- [3]Yonker M Secondary Headaches in Children and Adolescents: What Not to Miss Curr Neurol Neurosci Rep, 2018.PMID 30058035
- [4]Park EG; Yoo IH The diagnostic values of red flags in pediatric patients with headache Brain Dev, 2022.PMID 35568652
- [5]Friedman DI; Liu GT; Digre KB Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children Neurology, 2013.PMID 23966248
- [6]Inger HE; Rogers DL; McGregor ML; et al Diagnostic criteria in pediatric intracranial hypertension J AAPOS, 2017.PMID 29081363
- [7]Raoof N; Hoffmann J Diagnosis and treatment of idiopathic intracranial hypertension Cephalalgia, 2021.PMID 33631966
- [8]Gaier ED; Heidary G Pediatric Idiopathic Intracranial Hypertension Semin Neurol, 2019.PMID 31847041
- [9]Bulkowstein Y; Nitzan-Luques A; Schnapp A; et al The manifestations of metabolic acidosis during acetazolamide treatment in a cohort of pediatric idiopathic intracranial hypertension Pediatr Nephrol, 2024.PMID 37480382
- [10]Wilne S; Collier J; Kennedy C; et al Presentation of childhood CNS tumours: a systematic review and meta-analysis Lancet Oncol, 2007.PMID 17644483
- [11]Wilne S; Koller K; Collier J; et al The diagnosis of brain tumours in children: a guideline to assist healthcare professionals in the assessment of children who may have a brain tumour Arch Dis Child, 2010.PMID 20371594
- [12]Sheridan DC; Waites B; Lezak B; et al Clinical Factors Associated With Pediatric Brain Neoplasms Versus Primary Headache: A Case-Control Analysis Pediatr Emerg Care, 2020.PMID 29135901