29. Neurological disorders - Headache Flashcards
Types of Headaches
Headache is a frequent reason for older children and
adolescents to consult a doctor. The International
Headache Society has devised a classification, as shown
in Box 29.1, which defines
• Primary headaches: four main groups, comprising
migraine, tension-type headache, cluster headache
(and other trigeminal autonomic cephalalgias), and
other primary headaches (such as primary
stabbing headache). They are thought to be due
to a primary malfunction of neurons and their
networks.
• Secondary headaches: symptomatic of some
underlying pathology, e.g. from raised intracranial
pressure or space-occupying lesions.
• Trigeminal and other cranial neuralgias and other
headaches including root pain from herpes zoster.
Primary headaches (1/4) Tension-type headache
This is a symmetrical headache of gradual onset, often
described as tightness, a band or pressure. There are
usually no other symptoms.
Primary headaches (2/4) Migraine without aura
In children, episodes may last…
Characteristics
Accompanied by…
Aggravated/Relieved by…
This accounts for 90% of migraine. In children, episodes
may last 1–72 hours; the headache is commonly bilateral
but may be unilateral.
Characteristically pulsatile,
over the temporal or frontal area, it isoften accompanied
by unpleasant gastrointestinal disturbance such as nausea, vomiting, abdominal pain, photophobia and phonophobia (sensitivity to sounds).
It is typically aggravated by physical activity and relieved by sleep.
Primary headaches (3/4) Migraine with aura
Headache is preceded by…
The most common aura…
Visual disturbance auras include…
During a migraine attack, the patients prefer…
Accounts for 10% of migraine. The headache is preceded
by an aura (visual, sensory, or motor), although
the aura may occur without a headache. Features are
the absence of problems between episodes and the
frequent presence of premonitory symptoms (tiredness,
difficulty concentrating, autonomic features, etc.).
The most common aura comprises visual disturbance,
which may include:
• negative phenomena, such as hemianopia (loss of
half the visual field) or scotoma (small areas of
visual loss)
• positive phenomena such as fortification spectra
(seeing zigzag lines).
Rarely, there are unilateral sensory or motor symptoms
(e.g. hemiplegic migraine).
Migraine attacks usually last for a few hours, during
which time children often prefer to lie down in a quiet,
dark place.
Symptoms of tension-type headache or a migraine
often overlap. They are probably part of the same
pathophysiological continuum, with evidence that
both result from primary neuronal dysfunction, including
channelopathies, with vascular phenomena as secondary
events. There is a genetic predisposition, with
first-degree and second-degree relatives often also
affected. Bouts are often triggered by a disturbance of
inherent biorhythms, such as late nights or early rises, stress, or winding down after stress at home or school.
Certain foods, e.g. cheese, chocolate, and caffeine, are
only rarely a reliable trigger. In girls, headaches can be
related to menstruation and the oral contraceptive pill.
Primary headaches (4/4) Uncommon forms of migraine
Uncommon forms of migraine
These include:
• Familial hemiplegic migraine – caused by a calcium
channel defect, dominantly inherited.
• Sporadic hemiplegic migraine.
• Basilar-type migraine – vomiting with nystagmus
and/or cerebellar signs.
• Periodic syndromes – often precursors of migraine
and include:
– cyclical vomiting – recurrent stereotyped
episodes of vomiting and intense nausea
associated with pallor and lethargy. The child is
well in between episodes
– abdominal migraine – an idiopathic recurrent
disorder characterised by episodic midline
abdominal pain in bouts lasting 1–72 hours.
Pain is moderate to severe in intensity and
associated with vasomotor symptoms, nausea,
and vomiting. The child is well in between
episodes
– benign paroxysmal vertigo of childhood – is
characterized by recurrent brief episodes of
vertigo occurring without warning and
resolving spontaneously in otherwise healthy
children. Between episodes, neurological
examination, audiometric and vestibular
function tests are normal.
Secondary headaches (1/2) Raised intracranial pressure and space-occupying lesions
Headaches due to space-occupying lesions can be characterized by…
Other features suggestive of a space-occupying lesion are…
Headaches often raise the fear of brain tumours; this
may well be the reason for parents to consult a doctor.
Headaches due to a space-occupying lesion are worse
when lying downandmorning vomiting is characteristic.
The headaches may also cause night-time
waking.There is often achange in mood, personality,
or educational performance. Other features suggestive
of a space-occupying lesion are:
• visual field defects – from lesions pressing on the
optic pathways, e.g. craniopharyngioma (a
pituitary tumour)
• cranial nerve abnormalities causing diplopia,
new-onset squint or facial nerve palsy. The
VIth (abducens) cranial nerve has a long
intracranial course and is often affected when
there is raised pressure, resulting in a squint with
diplopia and inability to abduct the eye beyond
the midline. It is a false localising sign. Other
nerves are affected depending on the site
of lesion, e.g. pontine lesions may affect the
VIIth (facial) cranial nerve and cause a facial
nerve palsy
• abnormal gait
• torticollis (tilting of the head)
• growth failure, e.g. craniopharyngioma or
hypothalamic lesion
• papilloedema – a late feature
• cranial bruits – may be heard in
arteriovenous malformations but these
lesions are rare
• early or late puberty.
Secondary headaches (2/2) Medication overuse headache
Patients with primary headaches, especially migraine,
are at risk of developing a rebound “chronic daily
headache” (technically, headache on 15 or more days
a month) if they have a bad patch and use acute
analgesics or triptans on more than 2 days a week.
Withdrawing the offending medication will resolve this
in about 2 weeks.
Management
The mainstay of management is a thorough history
and examination with detailed explanation and advice.
Imaging is unnecessary in the absence of any ‘Red flag’
features.
Efforts should be made to make a specific headache
diagnosis and children and parents informed that
recurrent headaches are common. For most there are
good and bad spells, with periods of months or even
years in between the bad spells, and that they cause no
long-term harm. Written child-friendly information for
the family to take home is helpful. Children should be
advised on how to live with and control the headaches,
rather than allowing the headaches to dominate their
lives. There is nothing medicine can do to cure this
problem but there is much it can offer to make the bad
spells more bearable.
Rescue treatments
• Analgesia – paracetamol and nonsteroidal
anti-inflammatory drugs (NSAIDs), taken as early as
possible in an individual troublesome episode.
• Antiemetics – prochlorperazine or cyclizine, for
nausea.
• Triptans (serotonin (5-HT1) agonists), e.g.
sumatriptan. A nasal preparation of this is
particularly useful in children, early in a migraine
attack, together with a NSAID or paracetamol.
• Physical treatments such as cold compresses,
warm pads, topical forehead balms.
Prophylactic treatments
Where headaches are frequent and intrusive:
• sodium channel blockers – topiramate or
valproate
• beta-blockers – propranolol; contraindicated in
asthma
• tricyclics: pizotifen (5-HT2 antagonist) – can cause
weight gain and sleepiness, or amitriptyline – can
cause dangerous arrhythmias in overdose
• acupuncture.
Psychosocial support
• Psychological support – is it required to ameliorate
a particular stressor, e.g. bullying, anxiety over
exams, or illness in friends or family?
• Relaxation and other self-regulating techniques,
addressing life-style issues: ensuring adequate and
regular rest, play, sleep, water, and food.
