Case 20: 7yo - Headaches Flashcards
Headaches: when would you admit? what would you do for mgmt?
- intractable vomiting (esp. when awakening) ==> head-occupying tumor [non-contrast head CT]
- complex migraine + focal weakness
- intractable pain
- URI ==> leading to fever == sinus abscess [contrast CT]
Other signs that this is NOT migraine/cluster/tension ==> and you should admit
- swelling
- fever / infectious signs
- bleeding
- dehydration ==> DVTs in the brain == HA +/- facial swelling
14yo female hiking in Muir woods,presenting with seizure in ER that lasted for 5 min, then stopped. 10min later had another.
hx of a HA in the past few days, then fever
sinus infection ==> abscess
Mgmt = CT with contrast
W/up for severe HA
1) CT = bleed, space occupying lesion, abscess
2) MRI = slow, insidious process
3) lumbar puncture = CSF, infectious markers
headaches that usually present outpatient
1) Migraine
2) Cluster
3) Tension
Describe: tension HA
- location
- timing
- severity
“band “
- trigger: stress
- location = around the hand +/- occipital and posterior neck muscles
- timing =episodic, worsens throughout the day
- severity = mild to moderate
Describe: migraine HA
- location
- timing
- severity
“throbbing”
- triggers: stress, bright lights, odors, foods
- location - UL or BL
- severity = SEVERE
+ sxs= photophobia and/or phonophobia, abd pain, N/V
+ FHx migraines
==> relieved with sleep
periodic migraine syndrome == atypical “migraine variant” seen in pediatric group
- cyclical vomiting
- abdominal migraines
- benign paroxysmal vertigo
most common cause of recurrent HA in children
migraine
what atypical migraine symptoms are usually seen exclusively in peds?
periodic migraine syndrome == atypical “migraine variant” seen in pediatric group
- cyclical vomiting
- abdominal migraines
- benign paroxysmal vertigo
“classic” migraine v. “common” migraine
“classic” migraine
- WITH aura / speech changes / sensory changes
“common” migraine
- WITHOUT aura; UL (frontal, temporal)
most common type of migraine HA in children?
“common” migraine
- WITHOUT aura; UL (frontal, temporal)
diffdx of a HA that occurs with forceful vomiting after lying down
early morning, after a nap
- migraine
- increased intracranial pressure
diffdx of a HA that occurs with sudden onset
- migraine
- intracranial hemorrhage
diffdx of a HA that occurs after awakening from a nap
- migraine
- increased intracranial pressure
diffdx of a HA accompanied by fever and photophobia
- migraine
- infectious (meningitis, encephailitis)
diffdx of a HA that worsens with cough / valsalva
- migraine
- increased ICP
diffdx of a HA that progressively worsens
- migraine
- slow-growing intracranial process
diffdx for a child: HA + fever and tachycardia
serious infection - meningitis
- encephalitis
- intracranial abscess
diffdx for a child: HA + hypertension, bradycardia, irregular respirations
== Cushing’s triad
increased intracranial pressure
what are some classic signs associated with allergies/
- allergic shiners
- allergic salute
- dennie’s lines
- cobblestoning
define: allergic shiners
darkness and swelling beneath the eyes due to sinus congestion
define: allergic salute
frequent upward rubbing of nose d/t itching ==> transverse nasal crease along the lower third of the nasal bridge
define: dennie’s lines
infraorbital transverse creases
+ mild chronic inflammation of the conjunctivae
define: cobblestoning
fine granular appearance of teh palpebral conjunctivae d/t edema & hyperplasia of the papillae
==> cobblestoning of the pharynx d/t chronic nasopharyngeal drainage of allergic rhinitis and lymphocytic hyperplasia
define: ataxia
- diffdx (acute v. chronic)
ataxia = lack of coordination of muscle movements
- patho = dysfunction in various parts of nervous system (cerebellum, inner ear, dorsal columns)
diffdx ACUTE - post-infectious cerebellitis - infectious cerebellitis -medication / toxin - opsoclonus-myoclonus syndrome - migraine HA - psychiatric illness
CHRONIC
- intracranial mass
- hydrocephalus
- metabolic dz
- neurodegenerative dz
post-infectious cerebellitis causing ataxia
- age group:
- timing
- patho:
- sxs
- dx
- prognosis
== acute cerebellar ataxia
[diagnosis of exclusion]
- age group: 1-3yo
- timing = several weeks after a viral infection
- patho: (varicella/coxsackie) autoimmune response ==> cerebellar demyelination
- sxs = sudden onset ==> + ataxia, vomiting, nystagmus OR dysarthria
- dx = CSF nml or pleocytosis; LATER CSF protein is elevated (NO fever, NO systemic changes)
- prognosis = most recover within a few months
infectious cerebellitis causing ataxia
- patho:
- sxs
acute ataxia
similar to bacterial meningitis
- patho: viral (mumps, enterovirus, EBV)/ bacterial (Strep pneumo, Neisseria meningitidis, H. influenza B)
- sxs = + mental status changes
medication / toxin causing ataxia
- etiology
- sxs
acute ataxia
meds = anticonvulsants, antihistamines
toxin = EtOH
- patho = diffuse involvement of cerebellum + vermis, cerebellar hemispheres
- sxs = + B/L nystagmus, dysmetria
intracranial mass causing ataxia
acute/chronic ataxia - depends on extent of involvement
==> esp. with tumors in cerebellar / frontal lobe
+ specific sxs based on location (L sided nystagmus, L past-pointing, L hypotonia and hyporeflexia)
+ signs of increased ICP (papilledema, HA, emesis –> ? obstrucite hydrocephalus)
opsoclonus-myoclonus syndrome causing ataxia
- age group:
- timing
- patho:
- sxs
acute ataxia
- age group: 6mo-3y
- patho: paraneoplastic syndrome (esp. with neuroblastoma)
- sxs = + intermittent jerking movements (myoclonus) + erratic, jerky conjugate movements of the eyes (opsoclonus)
migraine HA causing ataxia
- age group
- patho
- sxs
acute ataxia
- age group = young women; children
- patho = basilar artery migraines / hemiplegic migraines ==> recurrent intermittent episodes of acute ataxia
1) sxs = intermittent loss of vision
+/- vertigo, arthralgia, dysarthria, limb & perioral paresthesias
2) transient loss of impairment of consciounsess/confused state
3) + B/L migraine sxs (throbbing HA - occipital), HA, vomiting
hydrocephalus causing ataxia
- timing
- sxs
chronic ataxia
- timing = insidious, chronic (weeks, months)
- sxs = + increasing loss of coordination, HA, vomiting
metabolic dz causing ataxia
- patho
intermittent or chronic w/ intermittent exacerbations
- patho = maple syrup urine disease, pyruvate decarboxylase deficiency
neurodegenerative dz causing ataxia
- age:
- patho
- sxs
chronic ataxia
- age = <10yo
- patho = ataxia-telangiectasia; Friedrich ataxia
- sxs = + loss of developmental milestones, other neuro sxs
psychiatric illness causing ataxia
- patho =
- sxs
acute ataxia
- patho = conversion reaction ==> hysterical involutnary disturbance in gait (astasia-abasia)
- Sxs = widely erratic, with lurching of the body when standing [CAN SIT NORMALLY]
rarely fall
most common cause of acute ataxia in children?
post-infectious cerebellitis == acute cerebellar ataxia
diagnosis of exclusion
describe the neurological exam finding associated with a lesion in this part of the brain: infratentorial
- cerebellar signs (ipsilateral)
- increased ICP signs
describe the neurological exam finding associated with a lesion in this part of the brain: cerebellar hemispheric
- changes in muscle tone, DTRs (ipsilateral)
- ==> hypotonia, hyporeflexia
describe the neurological exam finding associated with a lesion in this part of the brain: supratentorial
- focal motor and sensory abnormalities to the (CONTRALATERAL side)
describe the neurological exam finding associated with a lesion in this part of the brain: brain stem
- cranial nerve palsies
- gaze palsies
incidence of brain tumors in children
- overall, mortality, morbidity
- by age group
- by sex
brain tumor = most common solid tumor in children; 2nd most common form of childhood cancer (#1 = leukemia); #1 cause of cancer death in children
- more common in <7yo
- peaks in <10s, then in 70s.
- M>F (esp. ependymoma, medulloblastoma)
- <2yo (supratentorial tumors); 2-10yo (infratentorial), > 10yo (supratentorial tumors)
- increasing incidence, with decreasing mortality (though less so than other childhood cancers)
- morbidity = motor, neurocognitive, neuroendocrine sequelae
risk factors for brain tumors
- exposure to ionizing radiation
- genetic syndromes = tuberous sclerosis, neurofibromatosis Li-Fraumeni
Types of childhood brain tumors
- Medulloblastoma = 20%
- Juvenile pilocytic astrocytoma = 20%
- low grade astrocytoma = 15%
- high-grade astrocytoma = 7%
Describe: Medulloblastoma
- patho/location
- tx
- prognosis after treatment
== infratentorial primitive neuroectodermal tumor
- patho/location == malignant; can spread throughout CNS & mets to extracranial
- tx = surgical resection, radiation, chemo
- prognosis after treatment = depends on size & dissemination of tumor
Describe: ependymoma
- patho/location
- tx
- prognosis after treatment
- patho/location = 4th ventricle (ependymal lining) ==> hydrocephalussxs
- tx = surgical resection + radiation
- prognosis after treatment = 50% 5-y survival
Describe: astrocytoma of the cerebellum
- patho/location
- tx
- prognosis after treatment
== best prognosisof all infratentorial tumors in children
- patho/location= usually + cystic component
- tx= surgical resection; Rad tx (high-grade astrocytoma, partial resection, tumor progression via imaging)
- prognosis after treatment = 90% 5y survival with complete resection (less with partial)
Describe: brain stem glioma
- patho/location
- tx
- prognosis after treatment
- patho
AGGRESSIVE = diffuse infiltration of pons
LOW-GRADE = focal tumor in midbrian/medulla ==> surgical resection - prognosis after treatment (variable)
most common pediatric brain tumor
medulloblastoma
==infratentorial primitive neuroectodermal tumor
complications of childhood brain tumors
due to tumor itself
- obstructive hydrocephalus, especially if arising in the posterior fossa
- seizures
- hypothalamic-pituitary hormonal insufficiency
due to chemotherapy and/or radiation therapy
- neurocognitive defects
- ADD
- learning disabilities
- endocrine abnormalities
- stroke
what are the risk factors for overall IQ deficits in childhood brain tumors
- Younger age at time of treatment
- Longer time elapsed since treatment
- Female gender
- Hydrocephalus
- Use of radiation therapy and its extent and dose.
define: Romberg test
- patient to stand with feet together and arms extended anteriorly, palms upward ==> should be able to maintain upright posture with eyes opened AND closed with minimal swaying
(+) Romberg WITH EYES CLOSED ONLY
- diseases causing decreased position sense / abnormal vestibular function (otherwise, vision helps compensate with eyes open)
(+) Romberg WITH EYES CLOSED AND OPENED
- cerebellar pathology
first step in helping diagnose / manage a headache
1) HA diary
- Character of headache
- Duration
- Location
- Associated symptoms
- Activity at the time of the headache
- Potential triggers
- Actions that relieved the headache (alleviating factors)
2) f/up in 1-2 week
3) Ibuprofen/acetaminophen as needed
4) call if HA worsens significantly
how to visualize a suspected brain tumor
1) MRI = for posterior fossa (most common place for childhood brain tumors)
2) CT == esp. when + intracranial hemorrhage suspected (faster, no sedation needed)
Which of the following symptoms would raise concern for a life-threatening cause of Nicholas’ headaches?
A Headache accompanied by projectile vomiting.
B Sudden onset of severe headache.
C Headache that awakens one from sleep.
D Headache associated with fever and photophobia.
E Headache that worsens with cough or Valsalva maneuver.
F Intermittent headache, relieved by nonsteroidal anti-inflammatory drug.
G Headache occurring early in the morning.
everything except F = HA that have persisted for a long time without change are not as concerning.
b/c they CAN be due to migraines
but can also be due to scary reasons.
questions to consider during history taking of HA
OLDCARDS
- time of day
- other problems around the time of the HA
- brings on theHA
- do they cause waking up in the middle of the night
- does coughing or bending over to pick something up while you have a HA make it worse?
- hx of trauma (+/- LOS, emesis)
- stressors at home / school
- trouble sleeping
- ROS: fever, neck stiffness, change in vision / photophobia during the HA; gait; clumsiness/falling more than usual; dizziness
why is it important to assessment development when a kid has migraines?
- nml development is reassuring but does not exclude serious pathology
- abnml development ==> concerns for potential relationship between developmental delay and the HA (with temporal relationship between delay and HA)
Which of the following vital signs in a child of Nick’s age (7yo) with headaches would make you concerned about a possible life-threatening cause for the headaches? (Select all that apply.)
A Temperature = 104 F B Heart rate = 150 beats per minute C Blood pressure = 140/60 mm Hg D Respiratory rate = 10 breaths per minute E Heart rate = 60 beats per minute
All of the above
Normal VS for 6-12 RR = 20-30 HR = 70s-110s SBP = 80s-120s (70+2*7) = 84 Wt =20-40kg
diffdx for intermittent headaches for 1y that have recently worsened. Afebrile, no signs of increased ICP. hx of allergies. home stressors
- Migraine = esp. with family hx; triggered by stress
- Tension HA = triggered by stress + other somatic sxs of stress
- brain tumor = esp. b/c worsening (though would expect it to be for years) + FND, increased ICP
- sinusitis = poorly controlled allergic rhinnitis –> exacerbations of acute & chronic sinusitis + fever, purulent nasal discharge, sinus tenderness
idiopathic intracranial HTN
- epidemiology
- etiology
- patho
- sxs
- dx
diagnosis of exclusion
- epidemiology = mostly young girls
- patho = increased ICP in the absnce of intracranial mass lesion / hydrocephalus ==> d/t alterations in CSF absorption and/or production; abnomalities in vasomotor control & cerebral blood flow
- etiology = obesity, meds (vitA, tetracycline, OCPs, steroids), metabolic d/o (galactosemia, hypoPTHism), infections (sinusitis, chronic otitis media)
- sxs (mimics increased ICP) = HA, vomiting, diplopia (d/t paralysis of abducens nerve)
- dx == elevated CSF on lumbar puncture
1) increased ICP + HA, vomiting
2) normal brain anatomy
3) normal CSF - complications = blindness d/t transmission of elevated CSF pressure to optic nerve sheath
presence of nystagmus indicates?
nystagmus = rhythmic oscillation of the eyes (~ tremor)
can be horizontal/vertical/rotary
==> sign of cerebellar disease
diffdx
- tumors (nystagmus TOWARD the side of the lesion)
- toxins
- cerebellitis
- multiple sclerosis
what is periodic alternating nystagmus?
ystagmus with the fast component alternating between the right and left directions
diffdx:
- diffuse cerebellar lesions
- midline cerebellar lesions arising from the vermis or the nodule (e.g. such as cerebellar medulloblastoma)
lesion in cerebellum: vermis (midline)
dysarthria, truncal ataxia, and gait abnormalities
lesion in cerebellum: hemispheric
ipsilateral limb abnormalities, nystagmus, tremor/dysmetria and tend to spare speech.
fall to the side of the lesion; worse nystagmus when they look toward the side of the lesion
lesion in cerebellum: deep cerebellar nuclei
resting tremor, myoclonus, and opsoclonus such as that seen in children with a neuroblastoma
“What if, on Nick’s neurologic examination today, you’d found that he had papilledema, paresis and sensory loss over the right leg with 4+ reflexes at the patella and ankle also on the right—and that the rest of his neurologic examination was normal. With those findings, where would you think the lesion might be?”
Multiple Choice Answer:
A Supratentorial, on the right side of the brain
B Supratentorial, on the left side of the brain
C Infratentorial on the right side of the brain
D Infratentorial on the left side of the brain
E Brain stem
B
Nick is 7yo –> more likely to be supratentorial
supra = contralateral
infra / cerebellar = ipsilateral
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?
A Trial of prophylactic medication for migraine headaches
B MRI
C NSAIDs
D Referral to an ENT surgeon
A
throbbing = migraines
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.
NSAIDS = good for abortive therapy for migraines; but more often used for tension HA.
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?
A Daily headache diary B Computed tomography C Magnetic resonance imaging D Lumbar puncture E Intraventricular pressure monitoring
C
RED FLAGS (such that watchful waiting would be wrong)
increasing severity
+ ataxia
NO LUMBAR PUNCTURE in those who seem to have increased ICP (vomiting, possible pass effect) ==> concerns of herniation
CT is not as good at MRI at visualizing posterior fossa
A 3-year-old girl presents to the ED with sudden onset difficulty walking. She does not have a fever, headache, nausea, or vision changes, but two weeks ago she had a runny nose, a fever, and a rash. Musculoskeletal exam reveal no abnormalities of lower extremities. Neuro exam reveals bilateral horizontal nystagmus, wide based stance and swaying, and bilateral overreaching on finger to nose test. An LP is performed which reveals a normal CSF. Which of the following is the most likely diagnosis?
A Opsoclonus-myoclonus syndrome B Hydrocephalus C Infectious cerebellitis D Post-infectious cerebellitis E Migraine headache
D
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
A 12-year-old girl presents to her PMD complaining of a headache of gradual onset x 3 hours, non-provoked and described as a “big rubber band around my whole head” and a 5 out of 10 on the pain scale. The pain is not throbbing, and there is no associated photophobia, nausea or vomiting. The patient is afebrile, and there are no neurologic deficits during physical exam. Her mother states her pain is typically relieved with ibuprofen, but her mother is concerned that patient may have migraines because she has a few headaches every month after school. The child is otherwise healthy. What is the most likely cause of this girl’s headaches?
A Migraine B Tension-type headache C Brain tumor D Sinusitis E Pseudotumor cerebri
B
tension headache, helped with NSAIDs.
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
