Headache in child/adolescent Flashcards
How to assess hydration status
Ask - thirst, urine output (1-5ml/kg/hr or 4-6 in 24hr)
Look - sunken eye, moist Mucous membranes
Feel - Fontanelles, central CRT, Skin tumour, pulse rate (weak, thready, fast)
Common causes of Headaches
tension headache Eye strain Migraine sinusitis Central caries Raised intracranial pressure Infection analgesic headache Hypertension
features suggesting uncommon but serious underlying pathology e.g. brain tumour, meningitis, intracranial bleed.
Acute onset of severe pain worse on lying down Associated vomiting Developmental regression or personality change Unilateral pain HTN Papilloedema Increasing head circumference Focal neurological signs Presence of VP shunt Consistent location of recurrent headaches, age under 3 yr
Mx for migraine
Rest
Simple analgesia
adequate sleep
reduce stress
Avoid cheese, chocolate, citrus fruits, nuts and caffeinated drinks
Prophylaxis - beta blockers or pizotifen
In adolescent serotonin agonists eg sumitriptan during acute attack.
May cause post migraine third palsy or hemiparesis
Mx for tension headaches
reassurance that there is no serious pathology
Rest
Sympathy
Simple analgesia - paracetamol 15mg/kg
Address any underlying stress or anxiety in child’s life.
Minimise school absence
recognise headaches requiring urgent mx
Raised intracranial pressure
- Worse in mornings and with lying down
- Vomiting
- Papilloedema
- focal neurological signs
- HTN and bradycardia if severe.
Types of headaches
tension headache
Migraine
Clinical features of tension headache
Band-like pressure Worse late in the day precipitated by stress common in older school age children worse towards end of day Doesn't interfere with sleep Examination is normal
Cause of tension headache
contraction of neck or temporal muscles and are felt as a constricting band like ache
Differentiate migraine from tension headache
Migraine from tension type POUND P- pulsatile headache O -4-72 hOurs duration U - Unilateral, not bilateral N - Nauseas and/or vomiting D - disabling headache If 4-5 features than likely to be migraine.
Hx for PC headache
Fmhx
Good description of headache
- unilateral, bilateral
Associated symptoms e.g. vomiting, blurred vision
worse in the morning or when lying down - RICP
visual auras eg halos or zigzag lines = migraine
Photophobia and neck stiffness in addition to headache suggest meningitis
ask about nasal congestion and pain in the teeth or ears as infection around the skull can present as headache.
Bullying
Examination for headache
Record BP
feel pulse - Bradycardia
Examine fundi - signs of pailloedema
Neuro for focal signs
- Cerebellar - nystagmus, ataxia, intention tremor. Meduloblastoma
- Infratentorial - CN palsies
- Cerebral - focal seizures, spasticity
- Pituitary - Endocrine dysfucntion, visual field defects. Craniopharyngiomas.
Evidence of dental caries, sinus tenderness, audible cranial bruits
Cause of migraine
constriction followed by dilatation and pulsation of intracranial arteries.
Clinical presentation of migraine
start with aura
Throbbing unilateral headache with nausea and vomiting
Resolves with sleep
Pulsing pain
Photophobia
Phonophonia
In really young child it can be bilateral and children described as going pale.
Physical examination is normal.
Sleep deprivation and stress can predispose
how to dx a migraine
Episodic occurrence of headache Completely well between attacks Aura 20% in children Nausea - 90% Throbbing headache, Positive FmHx - material Impairment of normal function during attack Attack lasts between 1 and 72 hr.
