More than a migraine: Intracranial mass – medulloblastoma

Case presentation

A 6-year-old male with no significant medical history presents with headaches for the past 2 weeks. The headache is described as diffuse and, while occurring throughout the day, seems to be worse at night, at times waking him from sleep. He has also had daily first morning nonbilious, nonbloody emesis for the past week. There is no complaint of abdominal pain and there has been no fever or diarrhea. He does not appear to have vision changes and the parents report no difficulty ambulating or problems with balance. There is a strong family history of migraines in both his mother and older sisters. The child was seen by his primary care provider a few days after the headaches began and probable migraines were diagnosed. Oral magnesium was prescribed and his mother was asked to keep a headache diary and to give ibuprofen if acetaminophen was not helping. The mother has complied with these instructions. The ibuprofen and acetaminophen initially provided some relief but now do not seem to be helping. There is no recent travel and no other family members the child lives with have concurrent headaches.

The child’s physical examination reveals no fever, a heart rate of 83 beats per minute, respiratory rate of 24 breaths per minute, and blood pressure of 103/69 mm Hg. He does not appear ill but does complain of headache. He is normocephalic and there are no signs of trauma. His pupils are equal and reactive; there is no photophobia and no nystagmus. He ambulates without difficulty and has equal tone and strength throughout. There are no rashes or skin lesions.

Imaging considerations

In an acute setting, the common causes of pediatric headache include viral illness and migraine. The decision to obtain imaging in the pediatric patient with headache is based on history and physical examination findings. Most headaches in the pediatric population are not due to intracranial pathology. Over 90% of children who have an intracranial mass will have other historic or physical examination findings. Historic “red flags” include progressively worsening headache, waking in the middle of the night with a headache, complaints of morning headache upon awakening, morning emesis upon waking, duration of symptoms less than 6 months, and lack of a family history of migraine. Physical examination “red flags” include focal neurologic findings, worsening headache with Valsalva maneuver, and gait/balance disturbances. Children with these findings should be considered for neuroimaging.