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Headache may be the presenting complaint of serious diagnoses such as meningitis, brain tumor, or shunt malfunction, yet no previous studies have examined the spectrum of diagnoses for the pediatric emergency department (ED) population with a chief complaint of headache.In 1993, 53,988 visits were made to the ED of an urban children's hospital. Six hundred ninety-six patients (1.3%) had a chief complaint of headache. Half of these visits, distributed randomly throughout the year, were chosen for review; total sample size was 288.Patient age ranged from two to 18 years (2–5 years, 24.3%; 6–12 years, 57.6%; 13–18 years, 18.1%). The spectrum of ED diagnoses included viral illness (39.2%), sinusitis (16.0%), migraine (15.6%), post-traumatic headache (6.6%), streptococcal pharyngitis (4.9%), and tension headache (4.5%). No cases of brain tumor or bacterial meningitis were identified at the time of ED visit. The only serious neurologic conditions diagnosed were 15 cases of viral meningitis (5.2%), one shunt malfunction, one newly diagnosed hydrocephalus, one Bur-kitt's lymphoma patient with newly diagnosed CNS infiltration, and one punctate hemorrhage post head trauma. Two thirds of patients had radiologic and/or laboratory tests. Positive findings were as follows: 45.6% of sinus radiographs, 16.3% of rapid streptococcal antigen tests, 60.9% of lumbar punctures, and 19.0% of brain imaging studies. The frequency of serious and nonserious conditions as a cause of headache was compared to data from general EDs.Serious conditions presenting with the chief complaint of headache in the pediatric ED were not common in our population. The most frequent diagnoses in our review were viral illness, sinusitis, and migraine, in contrast to adult studies in which tension headache and migraine were most common. Only 6.6% of patients had serious neurologic diagnoses, which is in the range reported for general EDs. Of the serious conditions in our study, 80% were viral meningitis.