All in her head? Intermittent headache and vomiting in a 12-year-old
By Alyssa Harrison, MD
This 12-year-old girl is a rare visitor to your office. But today she's here, accompanied by her mother, with a complaint of headache and vomiting. The symptoms developed two weeks earlier, she reports, and have occurred intermittently since. Pain is localized to the occipital region but is occasionally bilateral frontal, occurs more often in the afternoon, and persists severely for five to 15 minutes and then dully thereafter. She doesn't complain of photophobia but does describe halos around objects, and tells you that colors "look weird" during headaches.
The patient had three episodes of vomiting on one day when the headache was present, two episodes on another. The vomiting was not self-induced, she insists, and was not associated with abdominal pain. She has not been awakened during the night or early morning by headache or vomiting; in fact, she reports, sleep relieves the headaches.
The girl cannot identify any triggers for the headaches, although her mother confesses to significant—but unspecified—family stress. Acetaminophen, the only medication that the girl takes, does not provide relief. She reports having had her first menstrual period two months earlier but not having one since.
The girl's medical history is vague. The mother recounts evaluation for rapid head growth in infancy, including a computed tomographic (CT) scan of the brain. There was a question of hydrocephalus at the time, but she was never treated surgically; the family was eventually reassured that follow-up was unnecessary. You perform a quick check of her head circumference: it's at the 98th percentile.
The family history reveals some interesting, perhaps relevant, information. Her mother has a history of migraine headache since 17 years of age, although symptoms subsided as she grew older. The mother's second pregnancy was complicated by birth defects, including hydrocephalus, and resulted in spontaneous abortion. The girl's father had congenital hydrocephalus that required placement of a shunt.
The physical examination shows you a well-appearing teenaged girl. Vital signs are normal, as is her general exam. No focal neurologic abnormalities are detected, and fundi show sharp disk margins.
Proceeding lacking clear direction
You consider the need for further work-up. Certainly, headache is a common complaint in children and adolescents, but rarely one that signals serious disease; clinical laboratory testing, electroencephalography, and brain imaging are usually uninformative. Are there features in this patient that prompt specific concerns? The visual aura, vomiting, and family history in the mother support classic migraine headache, although the occipital location and short duration are less typical. Recent stress could be the trigger for migraine or tension headache. You are most concerned about headache caused by intracranial pathology, however. It is reassuring to note that her headaches are marked by afternoon (as opposed to early morning) onset, that she has symptom-free intervals, and that the neurologic and funduscopic exams are normal.
Still, her uncertain history and strong family history of hydrocephalus create lingering doubt. Could macrocephaly in infancy be related to her current symptoms? You decide that brain imaging is indicated and order a CT scan of the head.
The patient and her mother—and you—are relieved to learn that the cranial CT is unremarkable. Confident that the headaches must be related to recent stress, they decline a trial of antimigraine medication. They agree to keep a headache diary and to return for follow-up in one month.
Two heads may not be better than one
At the next visit, you detect significant discrepancy between the history provided by the patient and her mother's account of her illness. Having failed to maintain a headache diary, the girl can only report that the headaches continue at a rate of least three times a week. Her mother disagrees: They're much less frequent. The patient insists that the pain is still severe (she rates most headaches at 8, on a scale of 1 to 10). General features of the headache are unchanged, although vomiting has completely resolved. But her mother disputes her, again, on the intensity of the headaches; she says she is sympathetic to her daughter's situation but is concerned that the girl is seeking secondary gain with her ongoing complaint. The mother's perception is that the headaches aren't incapacitating, occur at school only very rarely, and may allow her daughter to "escape" some of the conflict at home. You discuss this possibility further with mother and daughter, and all agree that counseling, with attention to stress management, should be initiated as soon as possible.
Milking the history
A long time passes before you see this patient again. She fails to keep several appointments. In a telephone conversation with you, her mother attributes the missed appointments to continued family stressors but reports that her daughter has generally been well.
Fifteen months later, the girl returns for a routine physical examination. Review of the time since her last visit reveals that the headaches have continued but are more easily tolerated. She does, however, have a new concern: Her first menses—reported longer than one year ago now—was the only one she experienced. She recalls that the vaginal blood flow on that occasion was scant and lasted only two days. She admits that she just assumed that her body "wasn't ready" to start menstruation, but now wonders aloud to you whether such a pattern—really, no pattern at all—is normal.