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Fall Child > 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
  • ·
  • · 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
  • 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 imagesCan 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
22
Q

Characteristics of cluster HAs

A
  • most common trigeminal autonomic cephalagia
  • Unilateral, frontal-periorbital region
  • Pain: severe, l
  • 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 directionSign of concussion

38
Q

Tools to evaluate concussion

A

ACE: Acute Concussion EvaluationCAT3, 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

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

Fall Child (4 decks)

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