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PEDIATRIC HEADACHES

PEDIATRIC HEADACHES. WAYNE BLOUNT, MD, MPH. OBJECTIVES. Primary care perspective The approach to a child with headache Types of headaches Who gets what work-up Who needs a referral. INTERNATIONAL HEADACHE SOCIETY (IHS). Guidelines and recommendations are for adults

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PEDIATRIC HEADACHES

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  1. PEDIATRIC HEADACHES WAYNE BLOUNT, MD, MPH

  2. OBJECTIVES • Primary care perspective • The approach to a child with headache • Types of headaches • Who gets what work-up • Who needs a referral

  3. INTERNATIONAL HEADACHE SOCIETY (IHS) • Guidelines and recommendations are for adults • No Peditricians on panel • Kids can’t describe pain as well as adults • Same type HA presents differently in kids

  4. THE APPROACH • Acute • Acute Recurrent • Chronic Progressive • Chronic non-progressive • Mixed

  5. THE APPROACH History Physical Labs Imaging

  6. HISTORY • The 7 characteristics of EVERY Symptom • Most important one of the 7 for Has • HA Diary

  7. THE PHYSICAL EXAM • HEENT • TRAUMA • INFECTION • COMPLETE NEURO EXAM

  8. WHAT DO WE KNOW ABOUT the H & P in PEDS HAs ? • ONLY 2 OF 150 KIDS HAD OCCIPITAL haS & BOTH HAD POSTERIOR FOSSA TUMORS • > 60% OF KIDS WITH SURGICALLY REMEDIABLE CONDITIONS WERE UNABLE TO DESCRIBE THEIR PAIN : a SIGN OF DECREASED VERBAL SKILL & MENTAL STATUS? • ALL KIDS WITH SERIOUS PATH PROCESS HAD NEURO SIGNS • EBM B

  9. THE APPROACH(TYPES OF HAs) • Acute • Acute recurrent • Chronic progressive • Chronic non-progressive

  10. WHAT DO WE KNOW ABOUT THE HA CAUSES • Viral Illness 39.2% • Sinusitis 16% • Migraine 15.6% • Post-traumatic 6.6% EBM B • Viral meningitis 5.2% • StrpPharyngitis 4.9% • Tension 4.5% • Other 7.7%

  11. SERIOUS NEUROLOGICAL DISEASES ARE FOUND IN 6 – 7 % OF PEDIATRIC Has • All had abnormal findings on Hx or P.E. • EBM B

  12. CAUSES OF ACUTE HAs • Cephalic Infections (Meningitis, Encephalitis & Brain abscess) • Non-cephalic Infections • Most Common Reason • Trauma • 29% kids with head trauma had HA • Unruptured AVM • 12/100,000 • “Thunderclap”

  13. CAUSES OF ACUTE HAs • HTN : Overcalled • Change in ICP: Neuro exam • Cavernous Vein Thrombosis: Neuro exam • Drugs : H2 blockers, steroids, TCN, ETOH, CO, OCPs, TMP-SMZ, MSG, Nifedipine, Cocaine, Marijuana • Stroke: Neuro exam • Ocular Disease : Uveitis, Glaucoma

  14. NON-CEPHALIC INFECTIONS • Viral • Sinusitis • Pharyngitis • Ocular

  15. THE APPROACH(TYPES OF HAs) • Acute • Acute recurrent • Chronic progressive • Chronic non-progressive

  16. ACUTE RECURRENT HA • Migraine vs Tension-type : • 2 ends of 1 spectrum ? • Both can be : • Episodic • Bilateral • No aura • Worsens • Brought on by stress • Assoc with neck pain

  17. COMMON RELAY CENTER(TRIGEMINAL NUCLEUS CAUDALIS)

  18. TRIGEMINAL NUCLEUS CAUDALIS • Receives Afferent messages and acts as a sensory relay center • Explains referral of pain to various locations

  19. CHRONIC PROGRESSIVE • Tumors • Worse in AM • Focality • Change in Growth pattern • Change in vision • Little things make it worse

  20. CHRONIC NON-PROGRESSIVE • Chronic Daily HA • Chronic Tension • New Persistent • Hemicrania Continua • Let a pediatric neurologist make these diagnoses

  21. WHICH CHILD NEEDS TESTS ? • Not very many • EEG very seldom helpful • Neuroimaging usually not helpful • Parents may insist • RED FLAGS

  22. RED FLAGS“SNOOP” • S ystemic sx or Secondary risk factors • N euro signs : the main reason • O nset : Thunderclap • O lder : Adults > 50 y.o. • P revious HA hx : 1st HA or different HA

  23. OTHER REASONS TO IMAGE • Presence of VP shunt • Presence of Neurocutaneous Syndrome : • Neurofibromatosis • Tuberous sclerosis • HA or emesis on awakening • Meningeal signs • Unvarying location of HA • Age < 3 y.o. • Chronic progressive pattern

  24. TREATMENT • Sleep Hygiene : Too – little, much, chaotic • Avoidance Diet ; • Un - substantiated, reasonable, cooperative • Look for triggers • Behavioral • Pharmacologic

  25. TREATMENT • Depends on cause : • Treat Infections • Migraine vs Tension

  26. ANALGESICS • Acetaminophen : 15 mg/kg/dose • Ibuprofen : 7.5 mg/kg/dose • Naproxen • Ketorolac

  27. TRIPTANS • Check PDR for FDA approval • Studies in kids : • Sumatriptan • Zolmitriptan • Rizatriptan

  28. ANTI-EMETICS • Promethazine • Prochlorperazine • Metoclopramide • Hydroxyzine

  29. TREATMENT PRINCIPLES • Give early • Give enough • Give for long enough : • Note length of usual attack from hx • Don’t use a 4-hr med for an 8-hr HA • Make Rx available • Avoid narcs

  30. PROPHYLAXIS • < 30 % WILL NEED IT • > 3 Has PER MONTH • DEARTH OF EVIDENCE IN KIDS • EXTRAPOLATED FROM ADULT STUDIES

  31. PROPHYLACTIC AGENTS • Cyproheaptadine : 0.25-1.5 mg/kg • Tricyclics : 1 mg/kg/day • Beta-blockers • NSAIDs • Calcium channel blockers • Anticonvulsants

  32. REFERRAL ? • Unclear DX • Complicated psychosocial dynamics • Treatment not working • Parental request

  33. CONCLUSIONS • Rely on Hx & P.E. • Use HA categories • Think Common, but remember the rare • Test when needed • Tailor treatment to HA pattern : Hx & Burden • Refer when needed

  34. QUESTIONS ? • OR PEANUT GALLERY COMMENTS

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