| Historical feature | Possible significance |
| Headache history |
| Age at onset | - Migraines frequently begin in the first decade of life.
- Chronic nonprogressive headaches begin in adolescence.
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| Mode of onset | - Abrupt onset of severe headache ("thunderclap headache" or "worst headache of my life") may indicate intracranial hemorrhage.
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| 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).
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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).
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| 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 worsen with lying down or resting.
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| 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).
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| 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.
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| 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.
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| 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.
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| 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).
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| 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.
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| Recent change in weight or vision | - May be associated with intracranial process (eg, pituitary tumor, craniopharyngioma, idiopathic intracranial hypertension).
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| Recent changes in sleep, exercise, or diet | - May precipitate headaches; may be associated with mood disorder.
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| Change in school or home environment | - May be a source of psychosocial stress.
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| Family history of headache or neurologic disorder | - Migraine and some tumors and vascular malformations are heritable.
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| What do child and parents think is causing the pain? | - Indicates their levels of anxiety about the headache.
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| Mental health history/symptoms, psychosocial stressors | - Chronic nonprogressive headaches may be associated with depression or anxiety.
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