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Headache Michael Babcock Summer 2013. Pediatric Neurology Quick Talks. Scenario. 7 yo boy Headaches for 4 months Headaches last 90 minutes Grabs the front of his head when it hurts Has about 1 headache a week, vomits with some of the headaches
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Headache Michael Babcock Summer 2013 Pediatric Neurology Quick Talks
Scenario • 7 yo boy • Headaches for 4 months • Headaches last 90 minutes • Grabs the front of his head when it hurts • Has about 1 headache a week, vomits with some of the headaches • Continues to do well in school, no vision complaints
Secondary Medication overuse (rebound) head/neck trauma Vascular disorder – SAH, AVM, vasculitis, CSVT High ICP / Low ICP Tumor Infection CNS Other infections Causes of headache • Primary • Migraine • Tension-type • Cluster • Paroxysmal hemicrania • SUNCT • Trigeminal neuralgia (not common in kids) • Chronic daily headache
History • Headache – quality, severity, location, laterality, onset, time course – episodic and similar or progressive/changing • Associated symptoms – systemic symptoms, fever, personality changes, seizures • Preceding symptoms – aura, gradual/rapid onset • Exacerbating features – migraines worse with activity; worse with laying or nocturnal or with cough/straining – signs of elevated ICP; worse with standing – signs of low ICP. • Medical history – NF1, Sturge-weber, connective tissue disorder, Sickle cell, immunocompromised.
Exam • Vitals – fever, ICP signs • Good neurologic exam • ? Altered mental status • Abnormal eye movements • Visual field testing • Fundoscopic exam • Focal weakness • UMN signs • Abnormal gait
CSF analysis Pseudotumor (IIH) Accurate recording of pressure, in lateral decub position must extend LE's. Meningitis Meningismus Fever New seizures AMS immunocompromised SAH Thunderclap headache Work-up • Imaging • Trauma • Associated seizures • AMS • Abnormal neurologic exam • Historical features – thunderclap headache, persistently lateralized, progressive course, shunt, change in pattern/type, occipital headache • Signs of elevated ICP • Considerations: • no family history of migraine • < 1 month of headache • Young age of onset • Prior to LP
Migraine • Affects 7% of all children • Causes $1-17 billion in lost productivity • Accounts for 10 million physician visits/year in U.S.
Migraine Classification • Pediatric migraine with aura • At least 2 attacks fulfilling B. • At least 3 of the following • One or more fully reversible aura symptom indicating focal cortical and/or brainstem dysfunction • at least 1 aura developing gradually over > 4 min or > 2 aura symptoms occurring in succession • No auras lasting > 60 minutes • Headache no more than 60 minutes after aura
Migraine treatment – Life-style modification • Sleep – don't vary by more than one hour on school/weekend nights • Exercise – regular exercise, but over-exercise can cause headache • Mealtimes – 3 meals daily, don't skip meals • Hydration – carry water bottle – school excuse to carry and go to bathroom • Stress – stress reduction techniques • Caffeine – moderation or stop • Analgesic overuse • Don't use OTC pain relievers more than two-three times weekly • Opiates can also cause this • To relieve headache – have to break cycle, stop medication, headache worse for 2-3 weeks, then better.
Migraine Medications - Preventative • Cyproheptadine – AAN PP – insufficient evidence – histamine and serotonin antagonist with Ca-channel blocking properties; SE – weight-gain and sedation. Can be OK for younger, non-overweight children. • Beta-blockers – conflicting evidence. SE – asthma, DM, orthostatic hypotension, depression, not good for athletes • Amitryptaline (TCA's) – depressino/affective disorder often co-morbid with migraines. SE – QT prolongation – get EKG, behavior change • Ca-channel blockers – Verapamil – good for hemiplegic migraine • AED's • Topamax – SE – weight loss, cognitive change, sedation • Depakote – SE – weight gain, PCOS, teratogenic; need CBC/LFT monitoring • Keppra – consider because low SE profile • Gabapentin – SE – sedation
Migraine Medications – Abortive • Naproxen (Aleve) – 10-20mg/kg/d div Q8H. For patients over 30kg. Can give 1-2 tabs at onset, 1 more tab in 8 hours. • Motrin • Fioricet (acetaminophen/butalbital/caffeine) or fiorinal – good for rescue but risk of dependance, overuse – probably best not to give outside ED. • Anti-emetics – Phenergan, Reglan, Compazine – can give benadryl to help with sleep/extrapyramidal effects • Triptans – Sumatriptan (PO, SC, IN) – Adult oral PO dose is 25-100mg at onset, max 200mg/day PO. No dosage recommendations for children in packet. SE-- heart – vasospasm, MI, arrhythmias, HTN, stroke, seizure, rebound headaches; chest/jaw/neck pain. • Ergots – nasal DHE (Migrinal nasal spray) – 1 squirt in each nostril – SE—chest pain, nausea, cannot use within 24 hours of triptan • In ED – hydration with NS, Magnesium, Depakote, Ketorolac if not medication overuse, compazine, benadryl, steroid
References • http://eyewiki.aao.org/Papilledema • http://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.html • AAN Practice parameter – migraines • Maria, B. 2009. Current management in child neurology. People's medical publishing house.