Childhood Headache 2

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Information about Childhood Headache 2
Health & Medicine

Published on February 6, 2009

Author: MedicineAndHealthNeurolog

Source: slideshare.net

Childhood Headache Rachel Howells

Learning Outcomes By the end of this session, you should be able to Differentiate primary from secondary headache Recognise and manage common primary headaches

By the end of this session, you should be able to

Differentiate primary from secondary headache

Recognise and manage common primary headaches

Epidemiology Preschool 1/3 will have had a headache Migraine headache 0-7% of population Schoolchildren 70% have ≥ 1 headache a year Peak at 90% at age 12-13 Prevalence of recurrent headache 20-30%

Preschool

1/3 will have had a headache

Migraine headache 0-7% of population

Schoolchildren

70% have ≥ 1 headache a year

Peak at 90% at age 12-13

Prevalence of recurrent headache 20-30%

Case 1

Case 1 15 year old girl Frontal headache, down neck and shoulders 2 months Start as soon as she rises from bed, and relieved by lying down Missing school for 6 weeks

15 year old girl

Frontal headache, down neck and shoulders

2 months

Start as soon as she rises from bed, and relieved by lying down

Missing school for 6 weeks

Primary or Secondary?

Case 1 Further history Spinal surgery 3 months ago Epidural anaesthesia Examination Normal

Further history

Spinal surgery 3 months ago

Epidural anaesthesia

Examination

Normal

Low pressure headache Possible dural tap Management Encourage mobilising Many spontaneously resolve within 3-4 months Short-term: Caffeine Long-term: Epidural blood patch

Possible dural tap

Management

Encourage mobilising

Many spontaneously resolve within 3-4 months

Short-term: Caffeine

Long-term: Epidural blood patch

Primary vs Secondary Headache

Primary vs Secondary Headache 10% of headaches seen in a specialist neurology / headache clinic are secondary in origin Population prevalence of organic disease is likely to be lower

10% of headaches seen in a specialist neurology / headache clinic are secondary in origin

Population prevalence of organic disease is likely to be lower

Secondary Headache Types Altered Intracranial Pressure Raised ICP Low Pressure Headaches Vascular Subarachnoid Headache (eg AVM) Dissection Vasculitis Drugs Drug effect Analgesia induced headache Central (thalamic) pain Trigeminal neuralgia Cluster headaches Local Dental Abscess Sinusitis Post head injury

How to identify a secondary headache

How to identify a secondary headache Brain Imaging Examination History

Indications that a headache is secondary to altered intracranial pressure

Indications Timing of headache Postural manoeuvres Associated symptoms

Timing of headache

Postural manoeuvres

Associated symptoms

Timing of Headache Morning but from sleep, before rising Raised Intracranial Pressure Morning but after getting up Low Pressure Headache

Postural Manoeuvres Getting up relieves headache Coughing and straining exacerbates it Raised Intracranial Pressure Lying down relieves headache Low Pressure Headache or Sinusitis

Associated Symptoms Frontal headache Associations Morning vomiting Other neurology Confusion Raised Intracranial Pressure Frontal headache Associations Pain / parasthesiae across shoulders* Blocked nose, facial pain ¤ Low Pressure Headache* or Sinusitis ¤

Case 2

Case 2 16 year old girl seen in OPD Frontal headache There when she wakes, gets better when she gets up No nausea or other neurological symptoms 4 months, not getting any worse

16 year old girl seen in OPD

Frontal headache

There when she wakes, gets better when she gets up

No nausea or other neurological symptoms

4 months, not getting any worse

Primary or Secondary? Is this raised or low intracranial pressure?

Case 2 continued Past History – nil Examination Enlarged blind spots on confrontation No other alteration of visual fields Papilloedema No ataxia, long tract signs

Past History – nil

Examination

Enlarged blind spots on confrontation

No other alteration of visual fields

Papilloedema

No ataxia, long tract signs

What diagnoses need to be considered?

Causes of Raised Intracranial Pressure Hydrocephalus Tumour obstructing CSF pathways Obstruction to CSF re-absorption (post haemorrhage or meningitis) Congenital (eg aqueduct stenosis) Cerebral oedema Inflammation (ADEM, stroke) Infection (meningitis etc) CO2 retention (obstructive sleep apnoea) Metabolic (DKA, other) Idiopathic (Benign) Intracranial Hypertension

Idiopathic Intracranial Hypertension Aetiology unknown Adolescent girls Obesity, drugs, steroid withdrawal Visual loss (10%) may be permanent and is only indication for treatment Raised intracranial pressure in the absence of space occupying lesion or obstruction to CSF flow

Aetiology unknown

Adolescent girls

Obesity, drugs, steroid withdrawal

Visual loss (10%) may be permanent and is only indication for treatment

Indications Timing of headache Postural manoeuvres Associated symptoms

Timing of headache

Postural manoeuvres

Associated symptoms

Case 3

Case 3 14 year old girl Headache since the evening before Single and worst headache ever Sudden onset Vomited once at start No history of head injury / prodrome

14 year old girl

Headache since the evening before

Single and worst headache ever

Sudden onset

Vomited once at start

No history of head injury / prodrome

Case 3 Examination Afebrile No meningism GCS 15 Unilateral facial weakness with frontal sparing Ipsilateral arm weakness with hyporeflexia

Examination

Afebrile

No meningism

GCS 15

Unilateral facial weakness with frontal sparing

Ipsilateral arm weakness with hyporeflexia

What diagnoses should you entertain?

CT brain

Case 3 CT shows haemorrhage around area of left basal ganglia Patient admits to using some cocaine at a party with her 18 year-old sister

CT shows haemorrhage around area of left basal ganglia

Patient admits to using some cocaine at a party with her 18 year-old sister

More information to help you identify secondary headache History

Timecourse Single or first severe headache Recurrent severe headaches One a month 2 years without progression Headaches all day on most days 18 months Headaches every few months then weeks then days Now every day Severe headaches all day for 12 days 2 months ago None since Bleed? Bleed? Tumour? TTH? Migraine?

Timecourse Single or first severe headache Recurrent severe headaches One a month 2 years without progression Headaches all day on most days 18 months Headaches every few months then weeks then days Now every day Severe headaches all day for 12 days 2 months ago None since

Pointers in History: Summary Timing of Headache Postural manoeuvres Symptoms associated with headache Timecourse

Timing of Headache

Postural manoeuvres

Symptoms associated with headache

Timecourse

Examination

Purpose of Examination To support your clinical impression made on history To rule out other differentials To adhere to many families expectations to be taken seriously to be able to support your view that nothing serious is going on

To support your clinical impression made on history

To rule out other differentials

To adhere to many families expectations

to be taken seriously

to be able to support your view that nothing serious is going on

Essential elements of Examination Vision Acuity Fields including blind spot Extraocular movements Long tract signs Tone Power Reflexes Cerebellar signs Finger-nose test (eyes shut) Tremor Dysarthria Gait Blood pressure Bruit Conscious level Fundi

Case 4

Case 4 8 year old boy with 10 month history of Bi-temporal headache Throbbing Worse with movement / exercise Mother says looks pale and unwell Usually start in morning Last all day

8 year old boy with 10 month history of

Bi-temporal headache

Throbbing

Worse with movement / exercise

Mother says looks pale and unwell

Usually start in morning

Last all day

Case 4 No family history Examination is normal

No family history

Examination is normal

Primary or Secondary? What is the most likely diagnosis?

Migraine without aura

What causes migraine? Migraine headache Nerve efferents – trigeminal, vagal Meninges have pain fibres with inputs from trigeminal complex Vasodilation of meningeal vessels Michael Creighton Why do some people get migraine headaches? Genetic Abnormal inhibitory inputs to trigeminal nerve complex

Migraine headache

Nerve efferents – trigeminal, vagal

Meninges have pain fibres with inputs from trigeminal complex

Vasodilation of meningeal vessels

Why do some people get migraine headaches?

Genetic

Abnormal inhibitory inputs to trigeminal nerve complex

Clinical Implications Abnormal inhibition to nociceptive parts of brain Abnormal response to changes in environment eg sleep, diet, smells Pain is exacerbated by noise and light Headache relieved by sleep in a dark room Migraine symptoms Pain involves the face (trigeminal) Throbbing pain (meningeal) Pallor and nausea (vagal) Delia Malchert

Abnormal inhibition to nociceptive parts of brain

Abnormal response to changes in environment eg sleep, diet, smells

Pain is exacerbated by noise and light

Headache relieved by sleep in a dark room

Migraine symptoms

Pain involves the face (trigeminal)

Throbbing pain (meningeal)

Pallor and nausea (vagal)

Migraine Classification Migraine without aura (commonest) Migraine with aura Basilar migraine Ophthalmoplegic migraine Alternating hemiplegia

Classification

Migraine without aura (commonest)

Migraine with aura

Basilar migraine

Ophthalmoplegic migraine

Alternating hemiplegia

Migraine The diagnosis is a clinical one Families can be reassured by Family history Longevity of symptoms Normal examination Addressing their underlying concerns

The diagnosis is a clinical one

Families can be reassured by

Family history

Longevity of symptoms

Normal examination

Addressing their underlying concerns

Management Explanation This is not a tumour Worst in second decade of life Most patients will get fewer headaches as they get older

Explanation

This is not a tumour

Worst in second decade of life

Most patients will get fewer headaches as they get older

Management 2. Treatment of attacks Analgesia as soon as an attack starts Ibuprofen works best (one RCT) May be supplemented by anti-emetic Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)

2. Treatment of attacks

Analgesia as soon as an attack starts

Ibuprofen works best (one RCT)

May be supplemented by anti-emetic

Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)

Management 3. Prevention – control of environment ‘ Sleep hygiene’ – regular sleep ‘ Diet hygiene’ – avoid long breaks ± snack before bed, avoid caffeine, low amine diet ‘ Exercise hygiene’ – regular exercise, maintain hydration Avoid stress – relaxation training, CBT

3. Prevention – control of environment

‘ Sleep hygiene’ – regular sleep

‘ Diet hygiene’ – avoid long breaks ± snack before bed, avoid caffeine, low amine diet

‘ Exercise hygiene’ – regular exercise, maintain hydration

Avoid stress – relaxation training, CBT

Management 4. Prevention – pharmacological No magic bullet, trial basis only Pizotifen Propanolol Feverfew

4. Prevention – pharmacological

No magic bullet, trial basis only

Pizotifen

Propanolol

Feverfew

Case 5

Case 5 10 year-old girl with 18 month history of Bilateral headache, mainly vertex Constant Comes on during day Not worsened by walking No aura or pallor / nausea 5/7 days a week, most weeks of the year

10 year-old girl with 18 month history of

Bilateral headache, mainly vertex

Constant

Comes on during day

Not worsened by walking

No aura or pallor / nausea

5/7 days a week, most weeks of the year

Case 5 No family history Examination normal Local grammar school Predicted for A grades in 10 GSCEs No external sources of anxiety – stable home, not being bullied Trying to keep going to school

No family history

Examination normal

Local grammar school

Predicted for A grades in 10 GSCEs

No external sources of anxiety – stable home, not being bullied

Trying to keep going to school

Case 5 Alternating ibuprofen 400mg and co-codamol for headaches ‘ Nothing really works’

Alternating ibuprofen 400mg and co-codamol for headaches

‘ Nothing really works’

Primary or secondary? What is the most likely diagnosis?

Chronic Tension-Type Headache

How is the diagnosis made?

CTTH No features suggestive of organic disease Time of day Postural manoeuvres Associated symptoms Time course Not classifiable as migraine Examination normal

No features suggestive of organic disease

Time of day

Postural manoeuvres

Associated symptoms

Time course

Not classifiable as migraine

Examination normal

Management Explanation Although not an organic disease, effects on life can be significant (school etc) Treat attacks Simple analgesia Avoid multiple drugs Feverfew / Levomenthol / TigerBalm

Explanation

Although not an organic disease, effects on life can be significant (school etc)

Treat attacks

Simple analgesia

Avoid multiple drugs

Feverfew / Levomenthol / TigerBalm

Management Prevention of attacks Sleep, diet, exercise hygiene Address anxiety (relaxation training, CBT) Maintain contact with school, try and attend but manage workload

Prevention of attacks

Sleep, diet, exercise hygiene

Address anxiety (relaxation training, CBT)

Maintain contact with school, try and attend but manage workload

What did you learn? You should now be able to Differentiate primary from secondary headache Recognise and manage common primary headaches Migraine with / without aura Tension-type headache

You should now be able to

Differentiate primary from secondary headache

Recognise and manage common primary headaches

Migraine with / without aura

Tension-type headache

Any questions?

Thank you for listening Rachel Howells

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