Headaches are a fairly frequent complaint in children, and most are not a serious problem. However, they may be an early symptom of serious disorders such as an intracranial tumor or idiopathic intracranial hypertension. A careful history and examination are necessary to determine whether additional testing or referral to a pediatric ophthalmologist or neurologist is indicated. If the history is consistent with migraine or tension headache and the examination is otherwise normal, symptomatic treatment may be all that is necessary. If the history or examination suggests the possibility of increased intracranial pressure, then imaging studies and referral to a pediatric neurologist are indicated.

The eyes themselves are rarely the cause of headache, but an ophthalmological examination may be necessary to rule out this possibility.

What Shouldn’t Be Missed

Migraine headaches are not uncommon in children. They may present with an initial complaint of abnormal visual phenomenon (prodrome). Recognition of migraines is important both for treatment and to avoid unnecessary testing. Less commonly, headaches may result from intracranial tumors or other serious disorders. The presence of papilledema indicates the need for prompt evaluation.

• 1. Migraine headache. Migraine headaches are more common in children than is often recognized. These may present with specific complaints of eye pain, which may be retro- or periorbital. Classic migraines are accompanied by prodromal syndromes, which are often visual, such as sparkling lights, jagged lines, or visual field defects (Figure 22–1). Most patients develop headaches in association with these phenomena, but the abnormal visual sensations sometimes occur without the headache (acephalgic migraine). The features of the headache, normal eye examination after the symptoms resolve, and the presence of a family history of migraines help in establishing a diagnosis.
  
• 2. Tension headache. Tension headaches also occur in children, but are less severe. Patients typically do not specifically complain of eye pain. The headaches tend to occur in specific situations, such as while at school.
  
• 3. Eyestrain. Eye problems rarely cause headaches, but an ophthalmological examination may be necessary if a diagnosis cannot be established. Patients with uncorrected refractive errors may squint chronically in an attempt to improve vision through a pinhole effect. Spectacle correction should resolve this problem. Occasionally, patients may have difficultly with accommodation (focusing of the lens at near) or convergence, which may cause complaints of eye fatigue or strain, particularly with reading.
  
• 4. Increased intracranial pressure. Headaches are a common symptom of increased intracranial pressure, which may occur for a variety of reasons. The visual acuity is usually normal unless the pressure is markedly elevated or prolonged to the point that optic nerve damage occurs. Etiologies include intracranial space-occupying lesions, hydrocephalus, and idiopathic intracranial hypertension (pseudotumor cerebri).