P HEADCHE WITH WOBBLE

 A

In this case, the patient is a 10-year-old boy presenting with chronic headaches that have been occurring for an extended period. His headaches seem to follow a pattern related to school and improve over the summer, which suggests a possible environmental or stress-related trigger. His neurological exam reveals mild wobbling when walking heel-to-toe, and his mother reports a history of migraines.

When considering the most likely indication of a secondary headache disorder, we need to be vigilant for red flags or findings that could indicate a cause other than primary headaches (such as migraine or tension-type headache). Secondary headaches can result from conditions like structural abnormalities, infections, or increased intracranial pressure.

Key findings to consider for a secondary headache disorder:

• Neurological signs: Focal neurological findings (e.g., vision changes, numbness, weakness, or tingling) or signs of increased intracranial pressure (e.g., morning headaches, nausea, vomiting, or altered mental status).

• Recent changes in headache pattern: If the headaches change in severity, frequency, or character, or if they become more persistent or occur at unusual times, it could indicate something more serious.

• Associated symptoms: Such as vision changes, nausea/vomiting (suggesting increased intracranial pressure), or behavioral changes.

In this case:

• Wobbling when walking heel-to-toe is a subtle neurological sign. While it may not be a dramatic finding, it raises concern for possible cerebellar dysfunction, which could be indicative of a more serious condition like a mass effect, space-occupying lesion, or structural abnormality in the brain.

• Chronic, recurrent headaches with a recent increase in frequency also raise suspicion, as the headache pattern has changed from occasional headaches to more frequent headaches associated with the school year.

Thus, the mild wobbling when walking heel-to-toe is the most likely indication that this patient may have a secondary headache disorder, as it could suggest a neurological cause beyond simple migraine or tension-type headaches.