Headaches Flashcards
The difference in presentation of headaches in younger children vs older children.
Younger children express pain differently than older children.
E.g. Younger children may present with crying, rocking, etcetera - While older children may present as fussy, not as active, crying, etcetera
Most important factor(s) in assessing headaches
History!
Ask the child first, then confirm with parent
OLDCARTS
Patterns, such as HA diary
Headache physical exam
Normal physical exam in primary headaches.
Secondary headaches usually also have normal physical exam, but potentially present with fever, nuchal rigidity, abnormal neurologic exam
Red flags from headache HISTORY
Patients under age 3 years Sickle-cell disease Immunosuppressed patients Malignancy Coagulopathy Right-to-left-shunt Cardiac pathologies Head trauma
Red flags on headache PHYSICAL EXAM
Abnormal neurologic exam (usually HA is secondary to another etiology. May present with ataxia, weakness, diplopia, abnormal EOM, nuchal rigidity)
Papilledema or retinal hemorrhages
Growth abnormalities (e.g. increased head circumference, short stature, obesity, abnormal puberty progression)
Signs of trauma
General red flags in pediatric headaches
Wakes child up!!!
Thunderclap headache or “worst headache of my life”
Persistent N&V, AMS, 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
Mnemonic for headache red flags
SNOOP - any of which prompts further investigation including brain imaging or MRI or CT
S - systemic symptoms, illness, or condition (eg pregnancy, CA, immunocompromised, fever)
N - neurologic symptoms or abnormal signs (eg AMS, confusion, papilledema, focal neurologic symptoms, seizures)
O - onset is new (particularly in age > 40) or sudden (thunderclap)
O - other associated conditions or features (e.g. trauma, drugs, toxins; headache awakens from sleep; worse with valsalva, exertion, or sex).
P - previous headache history is not consistent with new headaches. i.e. change in attack frequency, severity, or clinical features.
Pediatric migraine onset - differences in age and gender
Onset is greater in males than females (generally before puberty)
Males tend to onset around age 7
Females tend to onset around age 10
At puberty, migraines affect more girls than boys (changes with puberty shifts to present more in girls)
Signs and symptoms of migraines
Migraines:
- Recurrent episodes
- Last 2-72 hours when untreated
- Pain: Throbbing focal pain, moderate-to-severe intensity, worsens with activity (rapid motion, sneezing, straining)… remember that migraines are vasovagal!!
- Associated with nausea, vomiting, and abdominal pain [and photophobia]. Relief with sleep, dark and quiet room, etc.
Stages of migraine without aura
- Prodrome
- Headache
- Postdrome
Characteristics of prodrome
24+ hours prior to onset of headache
Euphoria, irritability, social withdrawal
Food cravings, constipation, neck stiffness, increased yawning
Characteristics of migraine headaches in toddlers
Episodic pallor, decreased activity, vomiting
Characteristics of migraine headaches in children
Bifrontal, bitemporal, generalized - “It hurts all over”
May present as more global headache than the classic unilateral
May present with associated nausea, photophobia, and/or phonophonia
Characteristics of migraine headaches in teens
More often unilateral than global Gradual onset and severity More classic presentation as it gets worse gradually Mild-moderate: Dull, deep, steady pain Severe: Throbbing, pulsatile
Characteristics of postdrome
Exhaustion
Some patients report elation/euphoria
When does aura usually develop with migraine and how long does it last?
IF the patient has aura, it will usually present 30 minutes prior to onset of HA.
Aura lasts 5-20 minutes
Most common types/characteristics of aura
VISUAL - spots in vision, visual changes, scotoma (a partial loss of vision or a blind spot in an otherwise normal visual field)
Can have weakness, numbness, tingling, dysphagia instead of visual aura
Less common types/characteristics of aura
SENSORY -
Unilateral tingling in limbs or face (including tongue, mouth), followed by numbness for up to 1 hour
Dysphasia
Motor weakness (incredibly rare)
Nonpharmacologic management of migraines
Assess and avoid TRIGGERS - Headache diary
Dark, quiet room with prodrome begins
Prescription/pharmacologic treatment for migraines.
NSAIDs/Acetaminophen for mild to moderate pain
Triptans for more severe migraines (e.g. sumatriptan)
Cluster headaches - pediatric prevalence
Rare in children under age 10 years
Characteristics of cluster headaches
Most common trigeminal autonomic cephalagia
Unilateral, frontal-periobital region
Pain: Severe
Duration: Less than 3 hours
Frequency: Recurrent over short time
Associated findings: Ipsilateral autonomic findings, such as lacrimation, rhinorrhea, ophthalmic injection, Horner syndrome
Cluster headache treatment
Minimize source of stress
Avoid triggers
Address comorbid sleep problems
Nonpharmacologic treatments (start before Rx) - CBT, biofeedback
Rx treatments: Acetaminophen or NSAIDs (equal efficacy)
When to initiate preventative treatment for cluster headaches
When the child has >4 headaches/month or headaches affect normal activities
Signs and symptoms of tension headaches?
Pain: Diffuse across forehead; Non-throbbing
Does not worsen with activity (different from migraine)
Severity: Mild-to-moderate severity.
Duration: Anywhere from half hour to 1 week
Associated findings: May have nausea, photophobia, or phonophobia
NOT associated with vomiting
Treatment for tension-type headache (TTH)
Minimize stress
Avoid triggers
Address cormorbid sleep problems
Nonpharmacologic treatments (start before Rx): CBT, biofeedback
Rx treatment: Acetaminophen or NSAIDs (equal efficacy)
Rx for FREQUENT or CHRONIC TTH - TCA (amitriptyline - rarely used with pediatrics), if OTC doesn’t work
Menstrual migraines - Criteria for diagnosis
Migraines that occur in close correlation with menses
Defined as 2 days prior to 3 days after the initial bleed
Occur with at least 2/3 of the individuals menstrual cycles
As compared to migraines without meneses: More severe, longer duration, less responsive to treatment.
These patients can also experience migraines outside of meneses
Most menstrual migraines are without aura
Menstrual migraines treatment
Same as non-menstural migraines: NSAIDs, APAP, triptans (severe). Preventative therapy
Controversial use of estrogen-progestin therapies - must consider the risk of stroke. Not for migraine with aura (most menstrual migraines are without aura).
What is pseudomotor cerebri?
AKA: Idiopathic intracranial hypertension
Is a diagnosis of exclusion
Has s/sx of increased ICP (>280 mmHG for oese or sedated child; >250 mmHg for nonobese, nonsedated child; Papilledema universally present in child with a closed fontanel)
No other causes of intracranial hypertension evidence on neuroimaging!!`
Clinical presentation of pseudomotor cerebri
Headache!! - Most often severe, rarely presents without
Transient visual obscuration
Intracranial noises (pulsatile tinnitus)
Photospia
Back pain
Retrobulbar pain!!! - pain with eye movement in any direction. Might indicate vision loss, which can be permanent!!
Diplopia
Mostly occurs post-pubery, BMI greater than 28 (overweight, obese)
Clinical characteristics and associated symptoms of pseudomotor cerebri headaches
Variable features - lateralized, throbbing, pulsadile, intermittent or persistent
Often severe headache and associated with nausea and vomiting
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, and frontal headache
Physical exam for pseudomotor cerebri
Papilledema - MOST consistent sign beyond infancy (fontanels close)!!
Visual field loss
Bulging fontanel with Macewen sign (drum like sound on palpation)
CN exam - 6th nerve palsy (Esotropia may be present or elicited in testing of EOMs)
Postural changes
Gait assessment
Diagnostics for pseudomotor cerebri
Urgent MRI to rule out other causes of increased ICP
If nothing on MRI, perform LP (which will show normal CSF with high opening pressure)
Pseudotumor cerebri is a diagnosis of exclusion!
Management of pseudotumor cerebri
MRI and referral to neurology/neurosurgeon
Lumbar puncture - can be therapeutic, allowing drainage in the dura to reduce the pressure
Rx: Diamox, short-term corticosteroids, lasix
Weight loss is helpful in reducing prevalence and s/sx
If severe presentation or vision involvement - optic nerve sheath fenestration of CSF shunting
Concussion symptoms
Headache Fatigue Dizziness, balance problems Poor memory Delayed speed of processing Light/noise sensitivity Irritability, crying Anxiety, depression Change in sleeping, nursing, eating patterns
Physical exam of concussion
Fontanel / Head circumference Mental status Motor exam DTRs Sensory function Cerebellar exam Saccades (eye movement)
What is saccades
Quick, simultaneous movement of both eyes between two phases of fixation in the same direction
Is a sign of concussion
Tools to evaluate concussion
ACE (Acute concussion evaluation)
CAT3/SCAT3 (Sports concussion assessment tool 3)
SAC (Standardized assessment of concussion)
BESS (Balance error scoring system)
Signs of concussion deterioration
Headache that worsens Seizures Focal neuro signs Lethargy Repeated vomiting (especially in AM) --- need a CT Slurred speech Can't recognize people or places Increased confusion, irritability, or excessive crying Weakness or numbness in arms or legs Neck pain/rigidity Extreme behavior change Loss of consciousness >30 seconds
Concussion - neuroimaging vs. observation in patients under age 2 years
CT: suspected abuse, focal findings, fractures, lethargy, bulging fontanels, persistent emesis, seizures, prolonged LOC
CT OR Observation: Self-limited vomiting, behavior changes, nonacute skull fracture, unwitnessed trauma/LOC
OBSERVATION/No CT: No AMS, no scalp hematoma, no LOC >5 seconds, no fracture, normal behavior, no high risk injury (e.g. fall > 3 feet)
Concussion - neuroimaging vs. observation in patients older than 2 years of age.
CT: focal findings, seizure, persistent AMS, lethargy, agitation, prolonged LOC
CT OR Observation: Vomiting, headache, brief or questionable LOC
OBSERVATION/No CT: No severe headache, no high risk injury, no vomiting, no basilar fracture, no LOC
Management of concussions
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 - only after all s/sx are gone
Signs and symptoms of postconcussion syndrome
Vague s/sx #1: Persistent headaches #2: Dizziness Nausea, memory impairment, poor attention, excessive crying, sleep changes, change in nursing or eating habits, easily upset/increased tantrums, sad or lethargic, lack of interest in favourite toys
Treatment for post-concussion sydrome
CBT and PT
Referrals - e.g. ENT for persistent vergio
Consider MRI if s/sx worsen or is disabling
Medications are supportive - APAP, motrin
Long-term complications of post-concussion sydrome
Headaches - Migraine disorders (50% with concussion), Tension-type headache (TTH) (most common)
Memory and learning problems
Post-concussion - when to return to school?
Headache-free 24 hours
Can read 30 minutes without headache
Strict guideines! If headache occurs at school, go to the nurse or go home
Auditory learner at first
