Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got the previous case on Management of Common Pediatric Ear Complaints in the Emergency Department right.
Case Presentation: Emergency Department Management of Primary Headache Disorders in Pediatric Patients
An 11-year-old boy presents with the gradual onset of a severe throbbing bifrontal headache that started 12 hours ago…
- The boy complained of tingling on the right side of his face before the headache began, and he continues to complain of nausea. He has vomited twice. He spent most of the day in his room with the lights off. He has had several similar headaches in the past, but they lasted only a few hours and improved with ibuprofen and a nap.
- On review of symptoms, he denies any fever, infectious symptoms, or recent trauma, and has no significant past medical history. His examination is normal.
- What is the most likely diagnosis? Does he need blood tests or neuroimaging?
Case Conclusion
After conducting a careful history and physical examination of the boy with facial tingling, bifrontal headache, nausea, vomiting, and photophobia, you recognized that he fulfilled diagnostic criteria for migraine with aura. You reassured his mother that the tingling was a common aura in children, although potentially frightening to patients, caregivers, and ED staff who may have concerns about stroke. Moreover, the gradual onset prior to onset of the headache and subsequent resolution was typical of migraine aura rather than stroke. Similarly, his nausea and 2 episodes of vomiting were common symptoms associated with migraine. You also told her that you were reassured after clarifying that there was no pattern of early-morning vomiting or vomiting unassociated with headache, and that the boy had no neurologic symptoms between headache episodes. Most importantly, you were reassured by his normal general and neurologic examination. In this context, you explained your diagnosis, and that blood tests and neuroimaging were not necessary. The headache improved after treatment with IV metoclopramide, and the patient was discharged home after providing him and his mother with educational resources and headache tracking suggestions.
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Last Updated on March 13, 2025
