Evaluation

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There are a few red-flag signs and symptoms commonly used by clinicians to help differentiate when a headache could be dangerous. A common mnemonic adapted from adult literature is SNOOP4 or SNOOPPPPY.$^{47}$ (See Table 1.) One study found that the red-flag signs do not always mean that the underlying cause requires emergency treatment, and the severity of the cause is not correlated with the number of red flags.$^{48}$

Obtaining patient history (eg, age, medical comorbidities, and associated symptoms) is essential in the setting of a headache. Primary headaches are uncommon in children of preschool age, so patients aged 2 to 5 years who complain of headache should raise suspicion.$^3$ It is difficult to ascertain headache characteristics in preverbal and nonverbal children, so clinicians must adapt their approach when evaluating younger children with headache, giving attention to behavior changes, positional preference, and growth abnormalities. Patients with high-risk medical conditions (eg, CSF shunts, hemoglobinopathies, coagulopathies, vasculopathies, compromised immune systems) may be more likely to have a dangerous cause to their headache, and may warrant a more extensive workup. Additional targeted questions such as family history of headaches and pain medication overuse are helpful as well.$^{47}$ It is also important to inquire whether the patient is taking anticoagulant, blood-thinning, or procoagulant medications.

A complete neurologic examination includes mental status, cranial nerves, strength, motor, sensory, coordination, reflexes, gait, speech, cerebellar, visual field examination, and fundoscopic evaluation. Detection of asymmetry or abnormality warrants further investigation. Palsies in cranial nerves II, III, IV, and VI as well as papilledema on fundoscopic examination could indicate increases in ICP.$^{49}$ There is expanding research regarding ocular point-of-care ultrasound use in identifying increased ICP in pediatric patients, but future prospective studies evaluating diagnostic performance are still needed.$^{53}$

Young children sometimes have difficulty cooperating with the physical examination; therefore, careful observation of a child may be useful. A wealth of knowledge can be obtained by closely observing a child play or interact with a caregiver. Watch the child playing with a toy: do they use both hands equally to hold the toy? How is the child’s truncal tone and posture? A clear understanding of age-appropriate developmental milestones and when primitive reflexes should appear or dissipate are also valuable.$^{54}$

The Pediatric NIH Stroke Scale calculator is available from MDCalc.