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Headaches in Children

Headaches in Children. Today’s primary objective… -Learn 5 steps to evaluate and manage a child with headache in about 15 minutes! . 1) Exclude ominous headaches. Assessment: History Physical Examination (including any necessary CT or rarely, MRI) Will differentiate into:

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Headaches in Children

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  1. Headaches in Children Today’s primary objective… -Learn 5 steps to evaluate and manage a child with headache in about 15 minutes!

  2. 1) Exclude ominous headaches

  3. Assessment: • History • Physical Examination (including any necessary CT or rarely, MRI) • Will differentiate into: • “Benign” Primary headache -Migraine -Tension headache -Chronic daily headache • “Structural/Pathologic” Secondary headache -Mass lesion -Intercurrent Illness

  4. 1) Exclude ominous headaches Brain Tumor Headaches • Severe, incapacitating pain, often increasing in frequency or severity • Headache that occurs in the absence of previous headache or change in chronic headache pattern • Vomiting that is persistent, increasing in frequency or preceded by recurrent headache • Occipital or frontal, often focal • Awakens from sleep or pain on arising • Worse with valsalva-like maneuvers • Negative family history for migraine • Associated neurologic findings

  5. Brain tumor headaches are associated with neurologic findings (ex. Papilledema, strabismus, weakness or ataxia) in 85% of cases within 8 weeks of headaches onset and in virtually all cases by 24 weeks

  6. History • Define attributes of the pain -Onset/time of day (early morning, wakes from sleep) -Provocative/palliative factors -Quality of pain (throbbing, stabbing, pressure) -Radiation (location holocephalic or unilateral? Spreads to where?) -Severity -Temporal pattern (duration, frequency: recurrent, progressive, non-progressive) -Associated features (nausea, vomiting, abdominal pain, visual aura, diplopia, vertigo, dizziness, motion sickness, nocturnal leg cramps)

  7. Physical Exam • Vital signs (BP, temperature) • Head circumference • Palpation and percussion of the skull • Auscultation for bruits over neck, perhaps temples or orbits • Inspection of mouth and jaw • Percussion of sinuses and spine • Brudzinski’s sign • Kernig’s sign • Complete neurologic evaluation

  8. Lab Investigations -CT if: -focal symptoms -progressive disorders -symptoms of increased intracranial pressure -abnormal neurologic exam -Lumbar puncture if: -Infection -Inflammation -Pseudotumor cerebri -Cervical spine x-rays rarely helpful -EEG almost never helpful

  9. Pseudotumor Cerebri Causes: -Saggital sinus, lateral sinus thrombosis -Obesity -Pregnancy -Endocrine: Hypothyroidism, hypoparathyroidism -Drugs (tetracyclines, retinoic acid, vitamin A) -Iron deficiency anemia -SLE -Addison, Cushings disease, steroid withdrawal -Acromegaly -Idiopathic

  10. Pseudotumor Cerebri Treatment: -Address underlying cause -Ophthalmology consultation and follow formal visual fields -Acetazolamide 25mg/kg and more -Furosemide 2mg/kg -Dexamethasone 2mg qid -Monitor electrolytes -Serial lumbar puncture -Lumboperitoneal shunt -Optic nerve sheath fenestration

  11. 2) Think Migraine Guidelines -There is a continuum of benign, acute recurrent headache -Tension headache -Migraine without aura (common migraine) -Migraine with aura (classic migraine) -Complicated migraine/migraine equivalent -Frequency and severity of headache over time dictate differential diagnosis

  12. Characteristics of Adult Migraines -Episodic, recurrent, pulsatile headache, often frontotemporal, localized or Generalized -Premonitory sensory, motor, or visual symptoms (classic) -Described visual prodromes include scotoma, hemianopsia, transient blindness, fortification, spectra, and blurred vision lasting minutes to hours -Lasts 4 to 72 hours, occasionally minutes or days -Followed by nausea, vomiting, phonophobia, photophobia, or a desire to sleep. Relief follows sleep.

  13. Characteristics of childhood Migraine -Male predominance (60%) -Minor head trauma a common precipitant -Headache less often unilateral, 25-66% in kids vs. 75-91% in adults -Aura (ie. classic) often irritability, pallor, malaise, anorexia, less often visual (ex. fortification spectra, scotoma), sensory or motor -Shorter attacks, minutes to hours -Visual prodromes <40%; more typical is malaise, pallor, irritability, anorexia -Past history of motion sickness, 45% -Increased incidence of sleep disorders -Favorable prognosis

  14. History: -Are there warning symptoms -Do you have to stop what you are doing -Does the pain occur at any special time or under certain circumstances -Does the headache awaken the child -What do you think is causing your headaches? -Past history -Family history of migraine

  15. 3) Optimize non-pharmacologic techniques Migraine Management -Reassurance -Patient/Parent education, headache calendar -General non-pharmacologic treatment: -avoid triggers -headache diet -sleep regulation -daily exercise -alcohol abstinence -consider discontinuing oral contraceptives

  16. -stress/anxiety -menstruation -oral contraceptives -physical exertion -lack of sleep -school work -relationships -glare -weather changes -drugs -fasting -foods -high altitudes -refractive error Common Triggers

  17. -Foods (partial list) -broad bean pods -aged cheese (tyramine) -chicken livers -avocado -nuts -sour cream -yogurt -bananas -MSG -Cold foods (ice cream) -Alcohol -red wine -brandy -gin -Sodium nitrite -hot dogs, bacon -processed meats -Caffeine -coffee, tea, some pain relievers Dietary Triggers

  18. Contraceptive Use -Barrier methods avoid the problem -Oral contraceptives may provoke headaches in women with a genetic predisposition to migraine -Oral contraceptives may exacerbate or vary the pattern of pre-existing migraine -Current formulations of contraceptives (50ug) have a significantly lower incidence of serious side effects than older products -Patient education is key

  19. Pharmacologic measures -Acute treatment -Analgesics -Abortive treatment -Prophylaxis

  20. -Analgesics -acetaminophen -ibuprofen -naproxen -codeine -meperidine -morphine -corticosteroids

  21. -Ergots/caffeine -Triptans -Sumatriptan -Zolmitriptan -Almotriptan

  22. -Non-Selective 5-HT agonists -ergotamine: -rectal -peak plasma in 1 hour -biologic effects in 10 hours -problems: nausea -dihydroergotamine (for acute migraine) -0.5 mg intranasal -may repeat in 15 mins -for intractable migraine, 0.5 mg IV every 8 hours for 3 days

  23. -Sumatriptan (5HT1B/1D receptor agonist) -mechanism = vasoconstriction -efficacious in kids >8, but off label if <12 -sub-cutaneous auto-injection or nasally (oral not as effective) -adverse effects: tingling, dizziness, warm/hot sensation, chest tightness, angina, cardiac arrhythmias

  24. 5) Prevent chronic daily headaches Symptomatic vs. Prophylactic treatment -consider prophylaxis if 4-5 migraines monthly -prophylactic therapy often requires symptomatic treatment for breakthroughs -avoid prophylactic polytherapy -maintain a headache calendar

  25. Prophylaxis -NSAIDS (naproxen) -Beta blockers (propranolol, atenolol) -5HT2 antagonists (cyproheptadine) -SSRI’S (fluoxetine, paroxetine) -TCA’S (amitryptyline, nortryptyline) -Anti-epileptics (valproic acid, gabapentin) -Calcium channel blockers (verapamil) -Riboflavin

  26. Chronic daily headaches Clinical Characteristics -Frequency >5 headaches per week, or >15 per month -bi-frontal location -severity varies -duration: -continuous with pulses -brief/frequent -analgesic abuse may promote or transform (ie. medication overuse headache/rebound headache)

  27. Treatment -Limit opiates/analgesics -TCA’S -non-pharmacologic techniques: -biofeedback -relaxation therapy -counseling -psych consult -hypnosis, mediation, yoga, acupuncture

  28. Why does treatment fail? -Diagnosis is incomplete or incorrect -Important exacerbating factors have been missed: -hormonal triggers -dietary or lifestyle triggers -psychosocial factors -Pharmacotherapy is inadequate -inadequate dosage or usage -inadequate duration of treatment -noncompliance -Inadequate non-pharmacologic treatment

  29. Primary Headaches: Migraine variants -Complicated migraine -hemiplegic -ophthalmoplegic -basilar artery -retinal -Migraine Equivalents -paroxysmal torticollis -paroxysmal vertigo -cyclic vomiting/abdominal migraine

  30. Benign paroxysmal vertigo -Abrupt, brief episodes of vertigo with ataxia in kids 2-6 -child appears frightened, with pallor, and may indicate feeling dizzy -rapid eye-movements or nystagmus may be observed or the eyes are open -vomiting may be prominent -no loss of consciousness -migraine variant -supportive treatment

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