An 8-year-old boy is brought to the office due to intermittent headaches for the past 6 months. The headaches occur once or twice a month and can last 2-10 hours. The patient describes them as "pounding like loud music" located over the entire frontal area. The headaches are often associated with nausea and either nasal congestion or rhinorrhea. The pain does not wake him from sleep. Each episode, the patient's mother gives him ibuprofen, which improves the pain. He sometimes worries about developing an episode while in school. He has missed 2 days of school due to headache and has spent this time with his mother, refusing to watch television or play video games due to the brightness of the screen. Vital signs are normal, and neurologic examination, including funduscopy, is unremarkable. Which of the following is the most likely cause of this patient's clinical presentation?

Question

An 8-year-old boy is brought to the office due to intermittent headaches for the past 6 months.  The headaches occur once or twice a month and can last 2-10 hours.  The patient describes them as "pounding like loud music" located over the entire frontal area.  The headaches are often associated with nausea and either nasal congestion or rhinorrhea.  The pain does not wake him from sleep.  Each episode, the patient's mother gives him ibuprofen, which improves the pain.  He sometimes worries about developing an episode while in school.  He has missed 2 days of school due to headache and has spent this time with his mother, refusing to watch television or play video games due to the brightness of the screen.  Vital signs are normal, and neurologic examination, including funduscopy, is unremarkable.  Which of the following is the most likely cause of this patient's clinical presentation?

Quizplus · Accepted Answer

11ec25c8_d603_2590_bc81_0bb0c00cc65a_MD0003_00 This patient has episodic, pounding headaches associated with nausea and improved by simple analgesia. These findings are suggestive of migraine, a common, primary headache disorder. Although migraine is most common in adolescent girls and women, young children can also be affected, with an equal incidence between boys and girls before puberty. Children with migraines typically have episodic, pounding (or throbbing) headaches that may be unilateral or bilateral and are often associated with nausea and vomiting. Photophobia and phonophobia may be difficult to determine in young children but can be inferred by refusal to watch television or play outside due to bright lights (ie, photophobia) and loud sounds (ie, phonophobia). Although not typically present in adults, autonomic symptoms are common in children and include facial sweating, conjunctival injection, tearing, and nasal congestion/rhinorrhea. Migraine is a clinical diagnosis, and initial pharmacotherapy is simple analgesia (eg, acetaminophen, nonsteroidal anti-inflammatory drugs). Concerning findings, such as neurologic deficits or rapidly increasing headache frequency or severity, warrant further evaluation (eg, neuroimaging). (Choice A) Chronic sinusitis typically presents with worsening nasal symptoms (eg, congestion, purulent drainage) lasting ≥3 months, in addition to headache, cough, or anosmia. This patient has discrete, not progressive, episodes of pain. (Choice B) Cluster headaches are characterized by severe bouts of pain, each lasting minutes to <3 hours. Associated autonomic symptoms (eg, tearing, nasal congestion) are common. However, cluster headaches are always unilateral and typically occur in adults. (Choice C) Generalized anxiety disorder presents with pervasive worries (eg, school, safety, health) that interfere with daily functioning and can be associated with headaches. This boy's occasional concerns about headache at school are normal, and he has missed only 2 days during acute episodes. In addition, photophobia would not be expected with anxiety. (Choice D) Idiopathic intracranial hypertension classically presents in overweight young women with recurrent headaches that may be pulsatile in quality and associated with nausea and vomiting. Papilledema (and sometimes abducens nerve palsy) is classically seen but not present in this patient. (Choice E) Medication overuse headaches typically occur >15 days a month due to excessive use of pain relievers. This patient takes ibuprofen infrequently, making this diagnosis unlikely. Educational objective: Migraines in young children often present with bilateral, throbbing headache, in addition to photophobia, phonophobia, nausea, or vomiting. In contrast to adults, children commonly have associated autonomic symptoms (eg, tearing, nasal congestion). References: Similarities and differences between migraine in children and adults: presentation, disability, and response to treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29071512) Cranial autonomic symptoms in pediatric migraine are the rule, not the exception. (http://www.ncbi.nlm.nih.gov/pubmed/23897870)

An 8-Year-Old Boy Is Brought to the Office Due to Intermittent