Headache in a child Flashcards
What are the nutritional causes of migraines?
Wine, cheese, chocolate due to tyramine content
What is the main management of headaches in children?
60% can be treated conservatively: hydration, lifestyle changes
What is the acute management of headaches?
Sumatriptan
What is the MOA of sumatriptan?
Sumatriptan selectively binds to and activates serotonin 5-HT1D receptors in the central nervous system (CNS), thereby constricting cerebral blood vessels
What is the International Headache Society classification of headaches? Give examples of each.
- Primary headaches e.g. migraines, tension-type, cluster (+ other trigeminal autonomic cephalalgias), primary stabbing headaches.
- Secondary headaches e.g. raised ICP or SOC
- Trigeminal and other cranial neuralgias e.g. root pain from herpes zoster
What are the causes of primary and secondary headaches?
Primary - thought to be due to primary malfunction of neurons and their networks
Secondary - due to underlying pathology
Describe the features of a tension-type headache.
- Symmetrical
- Gradual onset
- “Tightness/band/pressure”
- No other symptoms
List 8 causes of secondary headaches.
VITAMIN CDEF - Vascular, Inflammatory / Infective, Trauma, Autoimmune, Metabolic, Iatrogenic, Neoplastic, Congenital, Degenerative, Endocrine and Functional
What are the different types of migraine?
- Migraine with aura
- Migraine without aura
Other forms:
- Familial hemiplegic migraine - caused by inherited calcium channel defect
- Sporadic hemiplegic migraine
- Basilar-type migraine - vomiting with nystagmuc and/or cerebellar signs
- Periodic syndromes - often precursors of migraine
Name 3 periodic syndromes which can precede migraine.
Cyclical vomiting - recurrent stereotyped episodes of vomiting and intense nausea associated with pallor and lethargy; well between episodes
Abdominal migraine - idiopathic recurrent, 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; well between episodes
Benign paroxysmal vertigo of childhood - recurrent brief episodes of vertigo without warning, resolving spontaneously in healthy children; normal examination between episodes
What is the most common type of migraine in children?
Migraine without aura - accounts for 90% of migraines
Describe the characteristics of migraine without aura. What makes it better/worse?
- Lasts 1-72 hours
- Bilateral but may be unilateral
- Pulsatile over temporal or frontal area
- +/- GI disturbance e.g. vomiting, nausea, abdominal pain
- Photophobia
- Phonophobia
Aggrevated by physical activity and relieved by sleep.
Describe the characteristics of migrain with aura.
- Headache preceded by aura
- Absence of symptoms between episodes
- Lasts a few hours
- Relived by lying down in quiet, dark place
What types of aura can precede a migraine with aura?
Visual, sensory or motor. Most commonly:
- negative phenomena e.g. hemianopia or scotoma
- positive phenomena e.g. fortification spectra
NB: Sometimes aura can occur without the headache
Does FH predispose to migraine?
Genetic predisposition with 1st and 2nd degree relatives often affected
What are the triggers of migraine in children?
Usually triggered by disturbance in inherent biorhythms e.g. late nights/early rises, stress at home or at school.
Foods are rarely a reliable trigger e.g. cheese, chocolate, caffeine.
In girls, menstruation of taking the oral contraceptive pill can be related to migraine.
What are the characteristics of a headache due to SOC or raised ICP?
- Worse when lying down
- Morning vomiting
- Night-time waking
- Change in mood, personality, educational performance
- Visual field defects
- CN abnormalities e.g. diplopia, squint, facial nerve palsy
- Abnormal gait
- Torticollis (tilting of the head)
- Growth failure
- Papilloedema (late)
- Cranial bruits (AVM but rare)
- Early or late puberty
Which space-occupying lesions can cause…?
- visual field defects
- false localising signs
- facial nerve palsy
- growth failure
- lesions pressing on optic pathways e.g. craniopharyngioma
- abducens nerve (CNVI) - has a long intracranial course and can cause false localising signs for the SOC –> diplopia, squint, inability to abduc eye past midline
- pontine lesions
- craniopharyngioma or hypothalamic lesions
What should you ask about in a headache history? What to look for on examination?
- Frequency, duration, character, position, radiation, triggers,, relieving and exacerbating, aura, premonitory symptoms
- Emotional/behavioural problems at home or school
- Vision checked
- Head trauma
- Alcohol, solvent or drug abuse
- Analgesia over-use
Physical signs:
- Visual acuity - refractive errors
- Sinus tenderness - sinusitis
- Pain on chewing - TMJ malocclusion
- BP - for hypertension
What are red flag symptoms for headache?
- Growth failure
- Visual field defects - craniopharyngioma
- Squint
- CN abnormalities
- Torticollis
- Abnormal coordination - for cerebellar lesions
- Gait - UMN or cerebellar lesions
- Fundi - papilloedema
- Bradycardia
- Cranial bruits - AVM
What is the definition of chronic daily headache? What is a common cause?
Headache on 15 or more days a month
This is a rebound headache in patients with primary headaches/migraines caused by medication overuse when using analgesics or triptans on more than 2 days a week. Withdrawing from the offending medication will resolve this within about 2 weeks.
What are the investigations for headache?
History and examination
Imaging - only in presence of red flag symptoms
What is the management of headache?
Rescue treatments
- Analgesia - paracetamol, NSAIDs taken early
- Antiemetics - prochlorperazine or cyclizine
- Triptans - nasal sumatriptan (5HT1 agonist) with NSAID/paracetamol is useful for attacks
- Physical treatments - cold compress, warm pads, topical forehead balms
Prophylaxis
- Na channel blockers - topiromate or valproate
- Beta-blockers - propranolol (CI in asthma)
- Trycyclics - pizotifen (5HT2 antagonists) but cause weighht gain and sleepiness; amitriptyline can cause arrhythmias.
- Acupuncture
Psychosocial support
- Psychologist - to ameliorate stressor e.g. bullying, anxiety, stress
- Relaxation/self-regulation techniques
