Tom is a 10-year-old boy referred to outpatients by his GP with a 2-year history of recurrent headaches.
Tom is a 10-year-old boy referred to outpatients by his GP with a 2-year history of recurrent headaches. He describes the pain as being of gradual onset, frontal, right-sided and throbbing. He has not noticed any visual symptoms. He takes paracetamol but it is of limited value. The headache is often preceded or accompanied by nausea and vomiting. His mother has noticed that he becomes very pale and quiet. He takes himself off to bed and sleeps for several hours after which he is fine. The episodes can last up to 12 hours. In between episodes Tom is fit and well. He is happy at school and doing well but missed 10 days last term due to headaches. He takes part in numerous after-school activities and loves performing arts, especially dance. He was admitted with a minor head injury at the age of 7 having fallen off his bike. There is no other significant past medical history and he takes no regular medication. His mother suffered with migraine as a teenager.
Tom is a healthy, well-grown boy. His height and weight are both on the 75th centiles.
His pulse is 68 beats/min and regular and his blood pressure 96/58 mmHg. Examination
of the cardiovascular, respiratory and abdominal systems is normal. His cranial nerves
are intact and fundoscopy is unremarkable. His peripheral nervous system is normal.
• What is the most likely diagnosis?
• What is the differential diagnosis?
• What investigations would you request?
• Is there any treatment that would reduce the frequency of these episodes?