Headaches Flashcards
Presentation of HAs in younger vs older kids
Younger kids express pain differently! (i.e. crying, rocking, etc)
Toddler – fussy, not as active, crying
Most important factor in assessing HAs?
- History!
- Child first, confirm w/parents
- OLDCARTS
- Patterns (HA diary)
HA PE
- Normal in primary HAs
- Usually normal in secondary HAs, but may have fever, nuchal rigidity, abnormal neuro exam
Red flags on HA history
- · <3 years old
- · sickle-cell disease
- · immunosuppressed
- · malignancy
- · coagulopathy
- · right-to-left shunt cardiac pathologies
- · head trauma
Red flags on HA PE
- 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
Red flag HA characteristics
- 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
Mnemonic for HA red flags
- 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.
Migraine onset: age and gender
- 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!
S/S of migraines
- 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)
Stages of migraine w/o aura
Prodrome, HA, postdrome
Characteristics of prodrome
- Euphoria, irritability, social w/drawal
- Food cravings, constipation, neck stiffness, increased yawning
- 24+ hours prior to onset of HA
Characteristics of migraine HA in toddlers
Episodic pallor, decreased activity, vomiting
Characteristics of migraine HA in children
Bifrontal, bitemporal, generalized w/N and photophobia/phonophobia
“hurts all over”
Characteristics of migraine HA in teens
- 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
Characteristics of postdrome
- Exhaustion
- Some people report elation/euphoria
When does aura usually develop w/migraine and how long does it last?
If they have it, usually 30 minutes prior to onset of HA, lasting 5-20 minutes
Most common characteristics of aura
VISUAL: spots in vision, scotoma, visual images
Can be weak, numbness, tingling, dysphagia instead of visual aura
Less common types of aura
- Sensory: unilateral tingling in limbs or face (including mouth and tongue), followed by numbness for up to 1 hour
- Dysphasia
- Motor weakness (incredibly rare)
Nonpharm mgmt. of migraines
- Headache diaries
- Assess triggers!
- Dark, quiet, room
- When prodrome happens, put them into a quite room
Rx for migraines
NSAIDs/ Acetaminophen for mild to moderate, Triptans for more severe migraines
Cluster HAs: age distribution
- rare in children < 10 years old
Characteristics of cluster HAs
- 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
Cluster HA Tx
- 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)
When to initiate preventive tx for cluster HAs
- when child has >4 headaches/month or headaches affect normal activities
S/S of tension HAs
- 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
TTH Tx
- 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
Menstrual migraines: criteria for Dx
- 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
Tx for menstrual migraines
- 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
What is pseudotumor cerebri?
- 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
Clinical presentation of pseudotumor cerebri
- 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
Characteristics of pseudotumor cerebri HA
- 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
PE for pseudotumor cerebri
- 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
Diagnostics for pseudotumor cerebri
- Urgent MRI to r/o other causes of increased ICP
- Nothing on MRI? à LP
- CSF nl with high opening pressure.
- Nothing on MRI? à LP
Diagnosis of exclusion!
MGMT. of pseudotumor cerebri
- 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
Concussion: Symptoms
- H/A
- Fatigue
- Dizziness, balance problems
- Poor memory
- Speed of processing
- Light/noise sensitivity
- Irritability, crying
- Anxiety, depression
- Change in sleep/nursing/eating patterns
Concussion on PE
- fontanel / HC
- Mental status
- Motor exam
- DTRs
- Sensory function
- Cerebellar exam
- Saccades
What is saccades?
Quick, simultaneous movement of both eyes between two phases of fixation in same direction
Sign of concussion
Tools to evaluate concussion
ACE: Acute Concussion Evaluation
CAT3, SAC, BESS
Signs of concussion deterioration
- 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
Concussion: neuroimaging vs observation when <2yo
- 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)
Concussion: neuroimaging vs observation when 2+yo
- 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
Concussion Mgmt approaches
- 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
S/S post-concussion syndrome?
- 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
Tx for post concussion syndrome
- CBT & PT
- Referrals: e.g., ENT for persistent vertigo
- Consider MRI if worsens, dissables
- Meds: tylenol, motrin
ong term complications of post concussion syndrome
- Headaches: migraine Dos (50% w/concussion!), TTH (most common)
- Memory and learning problems
Post concussion: when to return to school?
- HA free 24h, can read 30 min w/o HA
- Strict guidelines! If HA, go to nurse or go home
- Auditory learner at first
