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FALL15 N833 Adv Pedi Probs > Headaches > Flashcards

Headaches Flashcards

1
Q

Presentation of HAs in younger vs older kids

A

Younger kids express pain differently! (i.e. crying, rocking, etc)

Toddler – fussy, not as active, crying

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2
Q

Most important factor in assessing HAs?

A
  • History!
  • Child first, confirm w/parents
  • OLDCARTS
  • Patterns (HA diary)
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3
Q

HA PE

A
  • Normal in primary HAs
  • Usually normal in secondary HAs, but may have fever, nuchal rigidity, abnormal neuro exam
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4
Q

Red flags on HA history

A
  • · <3 years old
  • · sickle-cell disease
  • · immunosuppressed
  • · malignancy
  • · coagulopathy
  • · right-to-left shunt cardiac pathologies
  • · head trauma
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5
Q

Red flags on HA PE

A
  • Abnormal Neuro Exam
    • This is 2ndary etiology
    • Ataxia
    • Weakness
    • Diplopia
    • Abnormal EOM
  • Papilledema or retinal hemorrhages
  • Growth abnormalities, i.e. increased head circumference, short stature, obesity, or abnormal pubertal progression
  • Nuchal Rigidity
  • Signs of trauma
  • Cranial bruits
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6
Q

Red flag HA characteristics

A
  • Wakes child up!!!
  • Thunderclap headache or “worst headache of my life”
  • Persistent nausea/vomiting, altered mental status, ataxia
  • Worse in recumbent position or by vasovagal causes
  • Chronic progressive pattern
  • Change in quality, severity, frequency, or pattern
  • Occipital headache
  • Recurrent and localized
  • Duration < 6 months
  • Doesn’t respond to medication
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7
Q

Mnemonic for HA red flags

A
  • Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy, immunocompromised state including HIV)
  • Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, papilledema, focal neurologic symptoms or signs, meningismus, or seizures)
  • Onset is new (particularly for age >40 years) or sudden (eg, “thunderclap”)
  • Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual activity)
  • Previous headache history with headache progression or change in attack frequency, severity, or clinical features
  • Any of these findings should prompt further investigation, including brain imaging with MRI or CT.
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8
Q

Migraine onset: age and gender

A
  • Onset younger in boys (7 years old) than girls (10 years)
  • At puberty, migraines affect more girls than boys
    • Changes with puberty as it shifts to girls!
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9
Q

S/S of migraines

A
  • Pattern: recurrent episodes that last 2-72 hours if untreated
  • Pain: throbbing focal pain, moderate to severe intensity, worsens with activity (rapid motion, sneezing, straining)
    • Migraines = Vasovagal!
  • Associated with nausea, vomiting, abdominal pain, and relief with sleep (dark, quiet room)
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10
Q

Stages of migraine w/o aura

A

Prodrome, HA, postdrome

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11
Q

Characteristics of prodrome

A
  • Euphoria, irritability, social w/drawal
  • Food cravings, constipation, neck stiffness, increased yawning
  • 24+ hours prior to onset of HA
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12
Q

Characteristics of migraine HA in toddlers

A

Episodic pallor, decreased activity, vomiting

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13
Q

Characteristics of migraine HA in children

A

Bifrontal, bitemporal, generalized w/N and photophobia/phonophobia

“hurts all over”

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14
Q

Characteristics of migraine HA in teens

A
  • More oftn unilateral than global, gradual onset & severity
  • More classic presentation as it gets worse gradually
  • Mild-moderate: dull, deep, steady pain
  • Severe: throbbing, pulsatile
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15
Q

Characteristics of postdrome

A
  • Exhaustion
  • Some people report elation/euphoria
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16
Q

When does aura usually develop w/migraine and how long does it last?

A

If they have it, usually 30 minutes prior to onset of HA, lasting 5-20 minutes

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17
Q

Most common characteristics of aura

A

VISUAL: spots in vision, scotoma, visual images

Can be weak, numbness, tingling, dysphagia instead of visual aura

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18
Q

Less common types of aura

A
  • Sensory: unilateral tingling in limbs or face (including mouth and tongue), followed by numbness for up to 1 hour
  • Dysphasia
  • Motor weakness (incredibly rare)
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19
Q

Nonpharm mgmt. of migraines

A
  • Headache diaries
    • Assess triggers!
  • Dark, quiet, room
    • When prodrome happens, put them into a quite room
20
Q

Rx for migraines

A

NSAIDs/ Acetaminophen for mild to moderate, Triptans for more severe migraines

21
Q

Cluster HAs: age distribution

A
  • rare in children < 10 years old
22
Q

Characteristics of cluster HAs

A
  • most common trigeminal autonomic cephalagia
  • Unilateral, frontal-periorbital region
  • Pain: severe, l <3 hours, recurrent over short period of time
  • Same-sided autonomic findings: lacrimation, rhinorrhea, opthalmic injection, Horner syndrome
23
Q

Cluster HA Tx

A
  • Minimize sources of stress
  • Avoid triggers
  • Address cormorbid sleep problems
  • Nonpharmlogical treatments: CBT, biofeedback
    • Start with this before Rx
  • Rx: Acetaminophen or NSAIDs (Equal efficacy)
24
Q

When to initiate preventive tx for cluster HAs

A
  • when child has >4 headaches/month or headaches affect normal activities
25
Q

S/S of tension HAs

A
  • diffuse pain: across the forehead
  • non-throbbing
  • mild to moderate severity
  • do not worsen with activity
  • last anywhere from a half hour to 1 week
  • May be associated with:
    • nausea, photophobia, or phonophobia
  • Not associated with vomiting
26
Q

TTH Tx

A
  • Minimize stress
  • Avoid triggers
  • Address cormorbid sleep problems
  • Nonpharmlogical treatments: CBT, biofeedback
    • Start with this before Rx
  • Rx: Acetaminophen or NSAIDs
    • Equal efficacy
  • Rx for frequent or chronic TTH: tricyclic antidepressants (amitriptyline – rarely used with pediatrics) if OTC doesn’t work
27
Q

Menstrual migraines: criteria for Dx

A
  • Migraines that occur in close correlation with menses (defined as 2 days prior to 3 days after the initial bleed)
  • Occur with at least ⅔ of the individuals menstrual cycles
  • As compared to migraines without menses:
    • more severe
    • longer duration
    • less responsive to treatment

Persons identified with this condition can also experience migraines outside of menses

28
Q

Tx for menstrual migraines

A
  • same as non-menstrual migraine:
    • Abortive therapy: NSAIDS, acetaminophen, triptans (severe)
    • Preventative therapy
  • Controversial use of estrogen-progestin therapies
    • *consider risk of stroke
    • not for with aura – most menstural migraines are without aura
29
Q

What is pseudotumor cerebri?

A
  • AKA Idiopathic intracranial hypertension (dx of exclusion). S/S of increased ICP.
    • >280 mm Hg for obese or sedated child
    • >250 mm Hg for nonobese, nonsedated child
    • Papilledema universally present in child with a closed fontanel
  • no other cause of intracranial hypertension evident on neuroimaging
30
Q

Clinical presentation of pseudotumor cerebri

A
  • HA: most often severe, rare to present w/o
  • Transient visual obscurations
  • Intracranial noises (pulsatile tinnitus)
  • Photopsia
  • Back pain
  • Retrobulbar pain
    • Pain with movement of eye in any direction
    • Might indicate vision loss! May be permanent
  • Diplopia
  • Mostly post puberty, BMI greater than 28 – obese
31
Q

Characteristics of pseudotumor cerebri HA

A
  • Variable features
    • Lateralized
    • Throbbing
    • Pulsatile
    • Intermittent or persistent
  • Often severe, associated N/V
  • worse with postural changes
    • When you lay down then sit up – fluid shift
    • Or relief with vomiting because release in ICP
  • Most commonly chronic, progressive, frontal
32
Q

PE for pseudotumor cerebri

A
  • Papilledema: most consistent sign beyond infancy
  • Visual field loss
  • Bulging fontanel with Macewen sign (drum like sound at palpation)
  • CN assessment: Sixth nerve palsy
    • Esotropia may be present or elicited in testing of EOMs
  • Postural changes
  • Gait assessment
33
Q

Diagnostics for pseudotumor cerebri

A
  • Urgent MRI to r/o other causes of increased ICP
    • Nothing on MRI? à LP
      • CSF nl with high opening pressure.

Diagnosis of exclusion!

34
Q

MGMT. of pseudotumor cerebri

A
  • MRI and referral to neurology/neurosurgeon
  • LP- can be therapeutic, allows drainage in the dura to reduce pressure (therapeutic)
  • Diamox, short term corticosteroids, lasix
  • Weight loss is helpful in reducing prevalence and s/s
  • If severe/vision involvement: optic nerve sheath fenestration or CSF shunting
35
Q

Concussion: Symptoms

A
  • H/A
  • Fatigue
  • Dizziness, balance problems
  • Poor memory
  • Speed of processing
  • Light/noise sensitivity
  • Irritability, crying
  • Anxiety, depression
  • Change in sleep/nursing/eating patterns
36
Q

Concussion on PE

A
  • fontanel / HC
  • Mental status
  • Motor exam
  • DTRs
  • Sensory function
  • Cerebellar exam
  • Saccades
37
Q

What is saccades?

A

Quick, simultaneous movement of both eyes between two phases of fixation in same direction

Sign of concussion

38
Q

Tools to evaluate concussion

A

ACE: Acute Concussion Evaluation

CAT3, SAC, BESS

39
Q

Signs of concussion deterioration

A
  • H/A that worsens
  • Seizures
  • Focal nero signs
  • Lethargy
  • Repeated vomiting (especially in AM) à Need CT
  • Slurred speech
  • Can’t recognize people/ places
  • Increasing confusion, irritability, or excessive crying
  • Weakness/numbness in arms/legs
  • Neck pain/ rigidity
  • Extreme behavior change
  • Loss of conscioussness >30 seconds
40
Q

Concussion: neuroimaging vs observation when <2yo

A
  • CT: suspect abuse, focal findings, fractures, lethargy, bulging fontanels, persistent emesis, seizures, prolonged LOC
  • CT or obs: self-limeted vomiting, behavior change, nonacute skull fracture, unwitnessed trauma/loc
  • No CT: No AMS, no scalp hematoma, no LOC >5s, no fracture, nl behavior, no high risk injury (fall >3ft)
41
Q

Concussion: neuroimaging vs observation when 2+yo

A
  • CT: focal findings, seizure, perisstent AMS, lethargy, agitation, prolonged LOC
  • CT or obs: vomiting, HA, brief or ? LOC
  • No CT: no severe HA, no high risk injury, no vomiting, no basilar fx, no LOC
42
Q

Concussion Mgmt approaches

A
  • Physical and cognitive rest
  • Return to daily activities: gradually as improving, naps, good sleep
  • Return to school: gradually, lower workload, breaks, no big exams, no gym
  • Return to sports: all S/S gone
43
Q

S/S post-concussion syndrome?

A
  • Vague
  • # 1: persistent HA
  • # 2: dizziness
  • nausea, memory impairment, poor attention, excessive crying, sleep changes, change in nursing or eating haits, easily upset/increased tantrums, sad or lethargic, lack of interest in fav toys
44
Q

Tx for post concussion syndrome

A
  • CBT & PT
  • Referrals: e.g., ENT for persistent vertigo
  • Consider MRI if worsens, dissables
  • Meds: tylenol, motrin
45
Q

ong term complications of post concussion syndrome

A
  • Headaches: migraine Dos (50% w/concussion!), TTH (most common)
  • Memory and learning problems
46
Q

Post concussion: when to return to school?

A
  • HA free 24h, can read 30 min w/o HA
  • Strict guidelines! If HA, go to nurse or go home
  • Auditory learner at first

FALL15 N833 Adv Pedi Probs (10 decks)

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