20: 7-year-old male with a headache

Question 1

Tension Headaches

Answer 1

may feel like a band around the head or involve the occipital area with accompanying tenderness of the posterior muscles of the neck

Question 2

most common cause of recurrent headache in children:

Answer 2

migraine HA

Question 3

“Classic” vs. “Common”

Answer 3

• -A “classic” migraine headache is one that is accompanied by an “aura,” which can include visual symptoms (bright spots in the visual field), speech changes or sensory abnormalities (such as paresthesias).
• -A “common” migraine headache-also referred to as migraine without an aura-is the most frequent type of migrainous headache seen in children; it is typically unilateral, frontal or temporal in location, but may involve any part of the head.

Question 4

sign of increased ICP

Answer 4

• sign of increased ICP
• sudden onset
• awakens from sleep
• accompanied by fever and photophobia
• worsens with cough or Valsalva
• progressively worsening

Question 5

Findings Associated with Allergies

Answer 5

• -allergic shiners
• -Allergic salute
• -Dennie’s lines: Infraorbital transverse creases
• -cobblestoning: fine granular appearance of the palpebral conjunctivae resulting from edema and hyperplasia of the papillae

Question 6

differential diagnosis of acquired ataxia: Post-infectious cerebellitis

Answer 6

• Post-infectious cerebellitis (otherwise known as acute cerebellar ataxia) is the most common cause of acute ataxia in children.
• Primarily a diagnosis of exclusion in children 1 to 3 years of age.
• Thought to be an autoimmune response leading to cerebellar demyelination.
• Occurs several weeks after a viral infection (e.g., varicella or coxsackie virus).
• Onset is sudden and consists of ataxia, vomiting, nystagmus in about half of the patients and dysarthria in some.
• CSF may be normal or have a pleocytosis; eventually the CSF protein is elevated.
• Majority of children recover completely within a few months.
• Not typically associated with fever or other systemic manifestations.

Question 7

differential diagnosis of acquired ataxia: Infectious cerebellitis

Answer 7

• may be viral or bacterial in etiology
• Fever is often an accompanying symptom.
• Mental status changes are often observed.
• Examples of pathogens include mumps, enteroviruses and Epstein-Barr virus.
• Bacterial pathogens include those that cause bacterial meningitis (e.g., Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type B.

Question 8

differential diagnosis of acquired ataxia: Medication or toxin

Answer 8

The ataxia may be accompanied by nystagmus and dysmetria and is usually bilateral, owing to diffuse involvement of the cerebellum including the vermis and the cerebellar hemispheres.

Question 9

differential diagnosis of acquired ataxia: Intracranial mass

Answer 9

• An intracranial mass may lead to ataxia that is acute or chronic, depending on how early the lesion is identified and the extent of involvement.
• Ataxia is most often associated with tumors in the cerebellum or frontal lobe.
• Associated findings depend on the precise area of involvement.

Question 10

differential diagnosis of acquired ataxia: Opsoclonus- myoclonus syndrome

Answer 10

• -A paraneoplastic syndrome that occurs most often with neuroblastoma, generally occurs in the younger child (6 months-3 years).
• -Ataxia is accompanied by intermittent jerking movements (myoclonus) and erratic, jerky conjugate movements of the eyes (opsoclonus).

Question 11

differential diagnosis of acquired ataxia: migraine HA

Answer 11

• -Basilar artery migraines or hemiplegic migraines can cause recurrent intermittent episodes of acute ataxia.
• -Accompanying symptoms may include intermittent loss of vision, change in speech, headache and vomiting.

Question 12

differential diagnosis of acquired ataxia: hydrocephalus

Answer 12

• Ataxia associated with hydrocephalus generally is insidious in onset and quite chronic with increasing loss of coordination over wks-mos.
• It is usually associated with headache and vomiting.

Question 13

differential diagnosis of acquired ataxia: Metabolic disease

Answer 13

• -Ataxia may be associated with a number of metabolic diseases such as maple syrup urine disease or pyruvate decarboxylase deficiency.
• -Here the ataxia may be intermittent or chronic with intermittent exacerbations.

Question 14

differential diagnosis of acquired ataxia: Neurodegenerative disease

Answer 14

• -There are several neurodegenerative diseases of childhood that present with ataxia: ataxia-telangiectasia and Friedrich ataxia are the most well known.
• -Most affected children are younger than 10, and their symptoms include a loss of developmental milestones, ataxia and other neurological symptoms.

Question 15

differential diagnosis of acquired ataxia: psych illness

Answer 15

• -conversion reaction can manifest as a hysterical involuntary disturbance in gait (patient truly believes something is wrong, but no physical pathology exists) known as astasia-abasia.
• -Unlike true ataxia, this gait is wildly erratic and involves lurching of the body which requires extraordinary balance.
• -The child is generally able to sit without difficulty, but when put in a standing position, immediately begins to sway at the waist.

Question 16

Different parts of the cerebellum have different functions, knowledge of which can help localize lesions within the cerebellum

Answer 16

• -Lesions within the vermis (midline) cause dysarthria, truncal ataxia, and gait abnormalities.
• -Cerebellar hemispheric lesions cause ipsilateral limb abnormalities, nystagmus, tremor/dysmetria and tend to spare speech.
• -Patients fall towards the side of the lesion and have worse nystagmus when they look towards the side of the lesion.
• -Lesions of the deep cerebellar nuclei cause resting tremor, myoclonus, and opsoclonus such as that seen in children with a neuroblastoma.

Question 17

Distinguishing Neurologic Examination Findings

Answer 17

–Infratentorial lesions usually present with cerebellar signs and signs of raised intracranial pressure (ICP).
–Cerebellar hemispheric lesions can cause changes in muscle tone and DTRs, but usually lead to hypotonia and
hyporeflexia.
–Supratentorial lesions more commonly lead to focal motor and sensory abnormalities on the side opposite to the lesion.
–Brain stem tumors will often be associated with cranial nerve and gaze palsies.

Question 18

Brain Tumors Incidence

Answer 18

Brain tumors are the most common solid tumor in children and are the second most common form of childhood cancer behind leukemia. The incidence of brain tumors has been increasing over the past several decades. The reasons behind this are not entirely clear.

Question 19

Brain Tumors Classification

Answer 19

Medulloblastoma (20%)
Juvenile pilocytic astrocytoma (20%)
Low-grade astrocytoma (15%)
High-grade astrocytoma (7%)

Question 20

Visualization of a Suspected Brain Tumor

Answer 20

• Magnetic resonance imaging (MRI) would provide excellent detail of the posterior fossa.
• Computed tomography (CT) is not good in visualizing the posterior fossa quite as well. In cases when intracranial hemorrhage is suspected or needs to be ruled out, a head CT may be valuable as the first test since it is often easier and faster to obtain than an MRI in some centers, and unlike MRI rarely requires sedation of the child.

Question 21

A 7-year-old boy presents with a five-year history of intermittent vomiting, vertigo, and throbbing unilateral headaches that seem to be induced by emotional stress and when his teacher wears perfume. He reports that the pain is not worsened by long naps or coughing. His mother reports that she has a history of headaches that started as a child and wonders if her son inherited this from her. His neurological exam shows no focal deficits. What is the next step in diagnosis or treatment?

Answer 21

This child is presenting with signs of both typical and atypical migraines and could be started on a trial of prophylactic medication. Tricyclic antidepressants (TCAs) are often used in children for migraine prophylaxis, which is the most likely diagnosis in a child with this constellation of symptoms.

Question 22

tension HA tx

Answer 22

NSAIDs

Question 23

A 7-year-old boy with a past medical history of headaches presents with increased frequency and severity of headaches along with new onset vomiting. When the patient was walking into the room, he had a wide stance and nearly tripped twice. Which of the following is the most appropriate next step

Answer 23

MRI is more expensive and less readily available than CT imaging. It also frequently requires sedation in pediatric patients. However, it provides the best detail of the posterior fossa, which is the most common location of pediatric brain tumors.

CT imaging is a faster and more convenient than an MRI and is very valuable in ruling out intracranial hemorrhage. However, it does not visualize the posterior fossa as well as MRI and would not be the modality of choice if MRI is available.

Question 24

Post-infectious cerebellitis

Answer 24

typically presents in a younger child with ataxia, nystagmus, vomiting and sometimes dysarthria. It is believed to be an autoimmune response leading to demyelination of the cerebellum occurring several weeks after a viral infection such as varicella or coxsackie virus.

Question 25

Tension-type headaches

Answer 25

often bilateral and involve the forehead, temporal areas, or back of the head. Tenderness of the posterior muscles of the neck may also be present. They should be responsive to NSAIDs. Stress can give rise to a tension headache, and this is consistent with this patient developing headaches after school.