headache is an extremely common condition in childhood , with a prevalence of 4050% by age 7 and 7075% by age 15 . the majority of headaches are benign and self - limited and can be accurately diagnosed on the basis of a careful history and physical examination ; although the frequency of headaches resulting from serious organic causes is low , this population may include children with conditions which require immediate medical care . while most studies are based on adults [ 29 ] , few surveys have examined the chief complaint of headache and its epidemiological impact in the pediatric emergency department ( ed ) [ 1013 ] . the purpose of this study was to : determine the demographic and clinical characteristics of patients presenting to the pediatric ed with a complaint of headache ; investigate the diagnostic work - up and therapeutic approach employed in these children ; study the impact of a specific follow - up . a retrospective study was performed in the ed of regina margherita children s hospital , a pediatric hospital which serves as the primary referral center for all pediatric diseases in the geographic area . all patients with a chief complaint of headache attending the ed between 1 october 2003 and 30 september 2004 , were eligible for inclusion . patients were excluded from the study if any of the following were present : post - traumatic headache , bacterial meningitis , notes not available for review or documentation not sufficient . during the period studied , 53.794 visits were made to the ed ; of these , database search identified 550 patients whose main complaint was headache . seven records had been excluded because of insufficient data . for each included patient a standardized data collection form was completed , recording the following data : patient age and sex , history of headache and associated symptoms , physical examination , results of laboratory exams , neuroimaging investigations and consultations , therapies administered and final diagnosis . final diagnosis was considered to be that recorded by the ed doctor for patients discharged and that recorded on the discharge summary for those admitted . headaches were defined as secondary if a specific cause was identified , and they were further divided into neurological and secondary to viral illnesses or respiratory infections . serious / pathological  diagnoses were defined as any disorder requiring a prompt intervention in ed , included any organic and structural involvement of the central nervous system ; for the purposes of this study , migraine was not considered a pathological disorder . after discharge from the ed and according to ed doctor final decision , many children with a diagnosis of primary headache were referred to our specialist headache center in order to be part of a follow - up program . during the period studied , 526 patients made 550 visits to the ed for headache complaints : 503 ( 95.6% ) children made a single visit , 22 ( 4.2% ) made two visits and one made three visits ( 0.2% ) . overall , non - traumatic headache accounted for 1% of total ed visits during the year studied . there were 265 males and 261 females , with a mean age of 8.8  years . the age ranges were as follows : 86 ( 15.6% ) pre - school children ( 05  years ) , 250 ( 45.5% ) primary school - age children ( 610  years ) and 214 ( 38.9% ) adolescents ( 1116  years ) ; five patients were aged 2  years or younger . number of repeated visits was 23 ( 4.2% ) . in 56.5% of cases ( 13 out of 23 ) return visit occurred in the week following the first ed visit ( mean time 3  days ) and was due to headache unresponsive to previous ed therapy ; in remaining ten cases ( 46.5% ) return visit was related to a new episode of headache , with a mean time of 84  days after the first ed visit . only four of these 23 patients ( 17.4% ) had been referred to headache center at discharge from first ed visit . ninety - seven patients were admitted to hospital for further investigations , with an admission rate of 17.6% . reasons for admission included : abnormal findings on history or physical examination ( such as long lasting headache , personality changes , vertigo , visual , motor or sensory symptoms , lethargy or loss of consciousness ) in 55 patients ( 56.7% ) ; severe vomiting in 25 patients ( 25.8% ) ; fever of unknown origin in nine cases ( 9.3% ) ; associated diseases , including ventriculoperitoneal ( vp ) shunt , brain malformations , cardiopathy and previous cerebrovascular diseases in eight children ( 8.2% ) . in six cases , data regarding final diagnosis were as follows : 312 cases ( 56.7% ) were diagnosed as having a primary headache disorder , 231 cases ( 42% ) had a secondary headache and seven ( 1.3% ) were discharged with a diagnosis that could not clearly account for their headache ( such as syncope or abdominal pain ) . migraine accounted for 5.4% of all visits ( 30 of 550 ) and for 9.6% of primary headaches ; among patients with migraine , in 19 cases ( 63.3% ) final diagnosis was made only after hospital admission . acute viral and respiratory illness ( i d upper respiratory infection , pharyngitis , sinusitis and gastritis ) represented the most frequent cause of secondary headache ( 90.5% ) and 38% of all attending headaches ( 209 of 550 ) . other less common causes of secondary headaches included hypertension , carbon monoxide exposure and neurological disorders . neurological disorders were found in 3% of all visits ( 17 cases ) , including two cases of vp shunt malfunctions , five cases of seizures , two brain tumors , two aseptic meningitis , three cerebrovascular diseases ( one intracranial hemorrhage , one ischaemic attack and one venous sinus thrombosis ) and three vestibular neuritis ; remaining  pathological  diagnoses included four cases of intoxication and one case of hypertension . all patients with neurological underlying diseases had a 100% rate of any pathological findings on history or physical examination , such as loss of consciousness , lethargy , vomiting , vertigo , hemiparesis , papilledema and focal motor signs . pathological  disorders were appropriately diagnosed and treated on their first visit to the ed . table  1headache etiology in pediatric emergency departmentdiagnosesn  =  550percentageprimary headache31256.7  not specified 28290.4  migraine309.6secondary headache23142  viral and respiratory infections20990.5 neurological 177.3  others52.2unclassified71.3others : hypertension and carbon monoxide intoxication headache etiology in pediatric emergency department others : hypertension and carbon monoxide intoxication a total of 155 specialist consulting visits were required ; in particular , neurological and ophthalmologist visits accounted respectively for 22.6% ( 35 of 155 ) and 44.5% ( 69 of 155 ) of these consultations . patients who underwent eeg presented on history or physical examination : focal motor or sensory signs ( seven cases ) , vertigo ( five cases ) , vomiting ( two cases ) or headache as the only symptom ( two cases ) . forty - four patients ( 8% ) underwent structural brain imaging during hospital attendance ; 6.8% of these were performed while the patient was under the care of the ed . overall , 11 neuroimagings ( 25% ) detected an abnormal finding , including hydrocephalus in vp shunt , brain tumors and cerebrovascular diseases . in 10 out of 44 patients ( 22.7% ) structural brain imaging was performed because of non - specific abnormalities observed at eeg ; in all cases a normal radiological finding was observed . the use of neuroimaging revealed in three cases the discovery of incidental benign abnormalities ( chiari i malformation , arachnoid cyst , non - specific white matter abnormalities ) . drug regimen and response to therapy was not clearly detailed on ed database records . table  2treatment of headache in pediatric emergency department  medicationn  =  223percentage  acetaminophene16071.7  nsaids 2611.7  noramidopyrine167.2  opiates156.7  antiemetics62.7 treatment of headache in pediatric emergency department on discharge from ed , only 212 out of 312 patients ( 67.9% ) with primary headache were referred to our headache center ; 114 of them ( 20.7% of the total population ) attended the center . among these 114 children , headache center staff diagnosed migraine in 29 patients discharged from ed with a diagnosis of  primary headache not otherwise specified  ; on the contrary , ed diagnosis of migraine was confirmed in all patients . only 2 out of 550 visits ( 0.4% ) to the ed for headache occurred in patients regularly followed in our headache center . in both cases reason for ed visit was headache associated with symptoms never experienced in the past . although headache is a common complaint in childhood ,   it is an unusual presenting symptom in ed . in our study , which represents the largest analysis of this complaint in a pediatric ed , [ 1013 ] we found that headache accounts for 1% of all visits . similar rates were reported in smaller pediatric series ( 0.71.3% ) [ 10 , 13 ] and in adult studies ( 14% ) [ 24 ] . regarding the italian experience , data from adult analysis show a prevalence ranging from 0.6% for primary headaches in ed   to 0.82.35% of all ed complaints [ 69 ] ; no italian pediatric series exist . compared to previously reported pediatric data , a similar high frequency in school - age children and a more homogenous male - to - female ratio was observed [ 11 , 13 ] . differential diagnosis of the patient presenting with headache is essential to rule out organic diseases and situation of immediate danger . earlier studies have shown that the most common cause of headache in childhood is secondary headache , mainly in the setting of an upper respiratory infection [ 1013 ] . compared with previous pediatric reports , an unexpected data obtained in our population was the higher prevalence of primary headache diagnosis versus secondary forms , being the proportion of patients classified with primary headache 56.7% in our study versus 10% in kan s   and 20% in burton s . similar proportion of primary headaches are usually reported in adults [ 9 , 14 ] and suggest an increasing awareness of primary headache as clinical disorder in childhood . the overall frequency of  pathological  diagnosis was low ( 4% ) and only a minority of children had neurological conditions such as proven vp shunt malfunction , brain tumor or cerebrovascular diseases . in all these patients , a detailed history and a careful neurological examination proved to be effective , enabling an appropriate diagnosis on first visit to ed . taking into consideration that our hospital is the referring regional center for all pediatric diseases , subsequent  pathological  diagnoses in other hospitals are improbable . despite the high frequency of primary headache diagnosis , most of these patients were discharged with a diagnosis of  primary headache not otherwise specified  and only 9.6% of them were classified as having a migraine . however , according with previous published data [ 2 , 5 , 7 ] , the main impression is that most of ed pediatricians stop the diagnosis process upon the differential diagnosis between primary and secondary headache . a low experience in headache classification according to international classification of headache disorders ( ichd ) 2004 criteria can be supposed . this might explain also the higher admission rate observed in our population ( 17.6% ) compared to previous studies . according with adults series , admission was more common for migraine patients [ 7 , 17 ] . with regard to diagnostic work - up , the number of specialist consulting visits requested by ed physicians was high ( 28.2% of all patients ) , similar to frequencies reported by other studies ( 1040% ) [ 8 , 18 ] . neuroimaging ( head ct scan or mri ) was performed on 8% of children , which on first glance appeared high given that 96% of all patients were ultimately diagnosed with a benign disease . our rates are not excessive and are fairly lower than that reported in other studies performed in the ed setting ( table  3 ) [ 3 , 10 , 13 ] . furthermore , 30% of radiological procedures with normal findings were performed because of non - specific abnormalities observed at eeg ; moreover , all eeg performed in absence of seizures resulted normal or showed non - specific abnormalities . according to practice parameters published by the american academy of neurology and the child neurology society , our data confirm that eeg is not recommended in the routine evaluation of headache , as it is unlikely to define an etiology and may lead to the discovery of incidental benign abnormalities , with subsequent unnecessary investigations and hospital admission . in general , diagnostic studies are seldom required in evaluating headache in children without clinical evidence of underlying structural lesions . neuroimaging should therefore be limited to children presenting to the ed with headache associated with symptoms and neurological signs predictive for intracranial pathology and in those with underlying risk factors ( such as vp shunt ) . table  3neuroimaging studies performed in the evaluation of headache in pediatric emergency department : comparison to the literature  author nn / percentage of neuroimaging percentage of abnormal findings  current study55044 ( 8)25  kan et al . 28821 ( 7.3)19  goldstein et al.5198490 ( 14.5)5.5 neuroimaging studies performed in the evaluation of headache in pediatric emergency department : comparison to the literature with regard to therapeutic approach , only a minority of patients ( 40.5% ) was treated with any type of analgesic . the use of acetaminophen was prevalent , with more than 70% of patients treated this way ; in a smaller proportion of our population other medications such as antiemetics and opioids were used . furthermore , all repeated visits occurring shortly after the first ed admission were due to headache unresponsive to previous ed therapy . it is unclear why pain relief is not a priority in pediatric ed , but it is possible that the severity of headaches in children presenting to ed is not as serious as that experienced by adults . the absence of clinical guidelines specifically designed for headache therapy in pediatric emergency may interfere also on this habit and on the choice of medications . no previous pediatric study has investigated the usefulness of a specific follow - up program for these patients . headache centers are dedicated to the treatment of primary headaches ; they are uncommon in pediatrics and generally have a long waiting list . in our hospital there is a collaboration with the ed : according to ed doctors final decision , patients discharged with a diagnosis of primary headache or headache not otherwise specified  are referred to our headache center and visited within 1015  days . we feel this alliance is very important and suggest it might play a role in containing the this is a very expensive cluster of patients , accessing the ed more than three times in a period of 6  months . in the us experience these are 10% of the total population , accounting for about 50% of headache - related visits to the ed ; using the same parameters , we found a low percentage of repeaters in our population ( < 1% ) . in particular , most of repeated visits ( 82.6% ) occurred in patients who had nt been referred to headache center after first discharge from ed . interestingly , only two patients regularly followed in headache center made a visit to the ed for headache complaints during the period studied . neverthless , a prospective case - control study should be conducted to better define and assess the real impact of headache center on the  repeaters  phenomenon . moreover , we suppose that collaboration between headache center specialists and ed staff might avoid unnecessary investigations in ed , as confirmed by the low rate of neuroimagings performed in our population compared with previous studies [ 3 , 10 , 13 ] . last but not least , we consider the importance of providing a follow - up visit for a correct diagnostic definition according to ichd-2004 criteria , as suggested by final diagnosis of migraine in children discharged from ed with a diagnosis of  primary headache not otherwise specified  . nevertheless , we found that only 67.9% of primary headaches presenting to ed were referred to headache center ; we observed also a low family adherence ( 53.8% ) to headache center referral . it is possible that main concern of families attending ed is to receive reassurance that their children s headache is not caused by a life - threatening disease ; similarly , the main purpose of ed pediatricians seems to be the exclusion of secondary  pathological  headaches . an exact diagnostic definition and a follow - up program are probably less significant for families and ed staff too . in conclusion , headache is a symptom accounting for 1% of all visits in our pediatric ed . the high frequency in the general pediatric population and vagueness of symptoms make headache a worrying symptom with the need to exclude a situation of immediate danger . at the same time , the majority of headaches are benign or secondary to self - limited viral illnesses ; serious conditions , such as neurological disorders , are rare and could be diagnosed on the basis of a careful history and a detailed neurological examination . use of diagnostic investigations , which represent a biological and economical burden for the whole population , should therefore be limited . pain relief does nt seem a priority in pediatric ed ; specifically designed guidelines are therefore needed in order to improve treatment of pediatric headache in the emergency setting . collaboration with headache center staff , might limit repeated visits in ed , avoid unnecessary investigations , provide a correct diagnostic definition according to ichd-2004 criteria and ensure an appropriate follow - up .
the objective of this study was to assess epidemiology , diagnostic work - up , treatment and follow - up of children presenting to emergency department ( ed ) with headache . 
 records of visits for non - traumatic headache to the ed of a pediatric hospital over a period of 12  months were retrospectively reviewed . 
 headache center charts were analyzed one year after . 
 five - hundred and fifty patients ( 1% of all ed visits ) were included . 
 spectrum of diagnoses was : primary headache ( 56.7% ) , with 9.6% of migraine ; secondary headache ( 42% ) ; unclassified headache ( 1.3% ) . 
 viral illnesses accounted for 90.5% of secondary headaches . a serious disorder was found in 4% of patients . 
 forty - four patients ( 8% ) underwent neuroimaging studies , with 25% of abnormal findings . 
 only 223 patients ( 40.5% ) received pharmacological treatment . on discharge , 
 212 patients ( 38.5% ) were referred to headache center and 114 ( 20.7% of all patients ) attended it . 
 ed diagnosis was confirmed in 74.6% of cases . 
 most of ed repeated visits ( 82.6% ) occurred in patients not referred to headache center at discharge from first ed visit . 
 the most frequent diagnosis was primary headache ; viral illnesses represented the majority of secondary headaches . 
 underlying serious disorders were associated with neurological signs , limiting the need of diagnostic investigations . 
 well structured prospective studies are needed to evaluate appropriate diagnostic tools , as well as correct therapeutic approach of pediatric headache in emergency . 
 collaboration with headache center might limit repeated visits and provide a correct diagnostic definition .