Important components of the headache history for children and adolescents

Historical feature	Possible significance
Headache history
Age at onset	Migraines frequently begin in the first decade of life. Chronic nonprogressive headaches begin in adolescence.
Mode of onset	Abrupt onset of severe headache ("thunderclap headache" or "worst headache of my life") may indicate intracranial hemorrhage.
What is the headache pattern: acute, acute recurrent, chronic progressive, nonprogressive daily, or mixed?	Helps to determine the cause (refer to the UpToDate topic on evaluation of headache in children)
How often does the headache occur?	Migraines typically occur 2 to 4 times per month; almost never daily. Chronic nonprogressive headaches may occur 5 to 7 days per week. Cluster headaches typically occur 2 to 3 times per day for several months.
How long does the headache last?	Migraines typically last 2 to 3 hours in young children and may last longer (48 to 72 hours) in adolescents. The duration of tension headaches is variable; they may last all day. Cluster headaches usually last 5 to 15 minutes but may last for 60 minutes.
Is there an aura or prodrome?	Aura or prodrome is suggestive of migraine; if the warning symptoms are focal and repeatedly located to the same side of the body, a seizure or vascular or structural cause should be suspected.
When do the headaches occur?	Headaches that wake the child from sleep or occur on waking may indicate increased intracranial pressure/space-occupying lesion. Tension-type headaches typically occur late in the day.
What is the headache quality (throbbing/pulsating, dull aching, squeezing, etc)?	Migraines have a throbbing/pulsating quality. Chronic nonprogressive headaches have a squeezing pressure or tightness that waxes and wanes. Cluster headaches have a deep continuous pain.
Where is the pain?	Occipital location may indicate posterior fossa neoplasms but also may occur in basilar migraine. Cluster headaches are usually temporal or retro-orbital. Localized pain may suggest a specific secondary etiology (eg, sinusitis, otitis, dental abscess).
What brings the headache on or makes it worse?	Headache in the recumbent position or with straining/Valsalva may indicate an intracranial process. Migraines may be triggered by certain foods, odors, bright lights, noise, lack of sleep, menses (in females), and strenuous activity. Tension-type headaches may worsen with stress, bright lights, noise, strenuous activity. Cluster headaches may be worsen with lying down or resting.
What makes the headache go away?	Migraines typically respond to analgesic medications, dark, quiet room, cool compress, or sleep. Chronic tension-type headaches may respond to sleep (but not to analgesic medications).
Are there associated symptoms?	Neurologic deficits (eg, ataxia, altered mental status, binocular horizontal diplopia) may indicate increased intracranial pressure and/or a space-occupying lesion. Fever may indicate infection, or rarely intracranial hemorrhage. Stiff neck may indicate meningitis, complicated pharyngitis, or intracranial hemorrhage. Localized pain may indicate localized infection (eg, otitis media, pharyngitis, sinusitis, dental abscess). Autonomic symptoms (eg, nausea, vomiting, pallor, chills, fever, dizziness, syncope, etc) may indicate migraine or cluster headache. Dizziness, numbness, and/or weakness may occur with idiopathic intracranial hypertension.
Do symptoms continue between headaches?	Persistence of symptoms (neurologic symptoms or nausea/vomiting) between headache episodes is suggestive of increased intracranial pressure and/or mass lesions. Resolution of symptoms between episodes is characteristic of migraine headaches.
Headache burden
Do the headaches impair normal functioning (eg, school attendance, activity) and quality of life?	Children with chronic nonprogressive headaches have frequent school absences; impaired function may warrant referral.
Additional information
Past medical history	Certain underlying conditions increase the likelihood of intracranial pathology (eg, sickle cell disease, immune deficiency, malignancy or history of malignancy, coagulopathy, cardiac disease with right-to-left intracardiac shunt, head trauma, neurofibromatosis type 1, tuberous sclerosis complex).
Medications and vitamins	Medications that may cause headache include oral contraceptives, glucocorticoids, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors, among others. Medications associated with idiopathic intracranial hypertension include growth hormone, tetracyclines, vitamin A (in excessive doses), and withdrawal of glucocorticoids.
Recent change in weight or vision	May be associated with intracranial process (eg, pituitary tumor, craniopharyngioma, idiopathic intracranial hypertension).
Recent changes in sleep, exercise, or diet	May precipitate headaches; may be associated with mood disorder.
Change in school or home environment	May be a source of psychosocial stress.
Family history of headache or neurologic disorder	Migraine and some tumors and vascular malformations are heritable.
What do child and parents think is causing the pain?	Indicates their levels of anxiety about the headache.
Mental health history/symptoms, psychosocial stressors	Chronic nonprogressive headaches may be associated with depression or anxiety.

Information compiled from:

Lewis DW, Koch T. Headache evaluation in children and adolescents: When to worry? When to scan? Pediatr Ann 2010; 39:399.
Rothner AD. The evaluation of headaches in children and adolescents. Semin Pediatr Neurol 1995; 2:109.
Strasburger VC, Brown RT, Braverman PK, et al. Headache. In: Adolescent Medicine: A Handbook for Primary Care, Lippincott Williams & Wilkins, Philadelphia 2006. p.25.

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Important components of the headache history for children and adolescents