Severe Headache in a Child: Intracranial Hypertension and Other Causes

A severe headache at the back of the head worsening with coughing or straining (Valsalva) is a classic sign of raised intracranial pressure (ICP). This requires urgent neuroimaging.

Intracranial Hypertension (IH) in Children

Elevated ICP (>28 cm H₂O in children) stretches pain-sensitive structures (dura, venous sinuses, vessels). Valsalva increases intrathoracic pressure → impedes cerebral venous drainage → transient ICP spike → headache exacerbation.

Common Causes

1. Meningitis/encephalitis: Fever, neck stiffness, photophobia, altered mental status.
2. Brain tumor: Posterior fossa tumors (medulloblastoma, ependymoma, pilocytic astrocytoma) often cause occipital headache + Valsalva worsening. Morning vomiting, ataxia, cranial nerve palsies.
3. Hydrocephalus: Obstructive (aqueductal stenosis) or communicating. Enlarged head (infants), sunset sign, developmental delay.
4. Traumatic brain injury: Epidural/subdural hematoma, contusion.
5. Cerebral venous sinus thrombosis (CVST): Headache + seizures, focal deficits. Risk: dehydration, hypercoagulable states, otitis/mastoiditis.
6. Idiopathic intracranial hypertension (IIH): Obese adolescent females. Papilledema, vision loss, pulsatile tinnitus.
7. Sinusitis: Sphenoid/ethmoid sinusitis can refer pain to occiput; less likely Valsalva-specific.

Urgent Evaluation

• Neurological exam: papilledema, cranial nerves, gait, fundoscopy.
• Emergent neuroimaging: MRI brain with orbits (preferred) or CT head if MRI unavailable.
• Lumbar puncture (opening pressure) if imaging negative and no mass lesion.

Do not delay. Posterior fossa masses can cause sudden herniation. Early diagnosis improves outcomes.