Module 2 (b) Pediatric Neurology - Headaches Flashcards
1
Q
Tics
A
- Sudden, brief intermittent movements (motor tics) or utterances (vocal tics)
- Almost always briefly suppressible
- Usually associated w/ awareness of an urge to perform the movement
- Up to 25% of children
- Some tics (PANDAS) follows Strep infection
2
Q
TICS
-Simple Motor and complex tics?
A
- Simple Motor — Nose wrinkling, eye twitching, lip biting, grimacing, shoulder shrug
- Complex Motor — Kicking, skipping, smelling things
3
Q
TICS
-Simple Vocal and Complex Vocal
A
- Simple Vocal — Coughing, throat clearing, sniffing, grunting
- Complex Vocal — Repeating words/phrases, animal sounds, yelling
4
Q
TICS
-Tourette Syndrome
A
- Persistent vocal and motor tics
- Onset age 2-15 yrs
- Associated w/ ADHD, OCD and behavioral problems
- Treatment
- Behavioral interventions
- Pharmacologic Therapy for Disabling and bothersome TICS
5
Q
TICS Patient Education
A
- Increased Tics associated with
- Focusing on the tic
- Stressful situations
- Lack of sleep
- Holding tics in for a long time
6
Q
Headaches
-Info
A
- Very common — 60% of children, 90% of adolescents
- Etiology
- Primary Vs Secondary
7
Q
Secondary Headaches
A
- Acute illness
- Post-traumatic HA
- Medications
- HTN — only hypertensive crisis
- Intracranial Hemorrhage
- Hydrocephalus
- CNS Tumor
- Idiopathic Intracranial HTN
- Medication overuse HA
8
Q
Imaging In Children w/ Headaches
A
- Imaging is indicated w/ HA + Abnormal neurological exam — MRI w/out Contrast is imaging of choice if HA is only concern
- Think of imaging with
- New onset HA in an immunosuppressed child
9
Q
HA imaging Algorithm
A
- FMH of Primary HA + Normal Neuro exam + Duration > 3-6 months - NO NEED TO IMAGE
10
Q
Signs and Sx’s of Increased ICP
A
- Abnormal Neuro Exam
- HA
- Recurrent or persistent N/V
- Papilledema
- Seizures
- Macrocephaly
- Behavioral changes
- Lethargy
11
Q
Neurocutaneous Syndromes
-Neurofibromatosis (NF-1)
A
- Multiple cafe au lait spots
- Axillae or inguinal freckling
- Skin neurofibromas
- Luis h nodules (iris)
- NF-1 has a strong association w/ CNS tumor
12
Q
Medication Overuse Headache
A
- Limit HA medication to less than 15 days per month
13
Q
Primary HA’s
A
- Tension-Type HAs
- Migraine — Menstrual-related Migraine and childhood migraine precursors
- Trigeminal Autonomic Cephalagias
- Less Common Primary HAs
14
Q
Primary HAs
-Tension-Type HA
A
- Bilateral, non-throbbing head pain of mild to moderate intensity (MOST COMMON)
- 30 minutes to 7 day duration
- NO N/V
- May have photophobia or phonophobia
- Not aggravated by routine physical activity - May have tightness/tenderness in occipital or cervical region
- Non-Pharmacologic treatment + Limited use of analgesia
15
Q
Phases of a Migraine Attack
A
- Prodrome — few hrs to days before
- Aura — 5 to 60 minutes prior to HA
- Migraine — Starts small and gets worse — 4-72 hrs — Needs to last at least 2 hrs for diagnosis
- Postdrome — 24-48 hrs — evidence that migraine has occurred
16
Q
Migraine w/out Aura
A
- More common than with Aura
- Recurrent HA lasting 2-72 hrs
- Moderate to severe intensity
- Pulsating quality
- Associated w/ nausea, photophobia, phonophobia
- Aggravated by routine physical activity
- Location typically frontal, bilateral, or holocephalic in children
17
Q
Migraine W/ Aura
A
- 14-30% and less common than w/out aura
- Typically precedes HA onset
- Gradual development over at least 5 minutes
- Duration no longer than an hour
- Transient and fully reversible
18
Q
Migraine W/ Aura
-Types of Auras
A
- Visual
- Small bright spot or small area of visual loss
- Scintillating scotoma or squiggles - Sensory
- Tingling in one limb or one side of the face
- Altered perception or sensation - Speech/Language
- Dysphasia
- Word-finding difficulty
- Impaired comprehension
19
Q
Migraine w/ Brainstem Aura
A
- No motor weakness
- Vertigo, dysarthria, tinnitus, diplopia, bilateral visual Sx’s, bilateral paresthesias, decreased consciousness, hypacusis
20
Q
Hemiplegic Migraine
A
- Aura includes motor weakness
- Typically starts in the hand and spreads up
- Typically unilateral - May take hrs to resolve
- Familiar vs sporadic
Get imagine w/ these children **
21
Q
Retinal Migraine
A
- Monocular visual aura
- Sudden loss of vision or perception of bright light in ONE eye only
- Spreads gradually
- Subsequent HA typically ipsilateral and Periorbital
22
Q
Menstrual Migraine
A
- Typically w/out aura
- Can have MM and non-MM.
- HA is caused by drop in estrogen levels and occurs a few days before menstruation
23
Q
Cyclic Vomiting Syndrome
A
- Repeated and usually stereotypical episodes of N/V that last for hours to days
- Well between episodes
- Often concurrent abdominal migraine
24
Q
Abdominal Migraine
A
- Recurrent episodes of abdominal pain w/ at least 2 additional Sx’s
- Anorexia, N/V, and pallor - Pain is midline or poorly localized; dull and moderate to severe intensity
- HA is not a prominent ft during attacks
- No photo/phonophobia
- Well between attacks
25
Q
Less Common Primary HAs
-Trigeminal Autonomic Cephalagias
A
- Short HA attacks w/ prominent ipsilateral cranial parasympathetic autonomic features
- Conjunctival injection and/or tearing
- Nasal congestion and/or Rhinorrhea
- Eyelid swelling
- Forehead and facial sweating
- Miosis and/or ptosis
RED FLAG HEADACHES ***
26
Q
Less Common Primary HAs
-4 types
A
- Primary Stabbing HA
- Primary cough HA
- Primary exertional HA
- New daily persistent HA
RED FLAG HA’s
27
Q
Management of Primary HAs
-Lifestyle Habits
A
- Consistency in
- Sleep
- Nutrition
- Low Stress
- Hydration
28
Q
HA Rescue Treatment
A
- Early
- Specific
- Comprehensive
- Appropriate
One of the biggest risk factors for having more migraines is INCOMPLETE TX of an individual attack **TEST
29
Q
HA Rescue Treatment
-Tension-Type HA
A
- Distracting activity or rest
- Warm or cool compresses
- If HA worsens, Tx w/ acetaminophen or NSAID
30
Q
HA Rescue Treatment
-Migraine
A
- Acetaminophen or NSAID +/- Triptan
2. Set limits for use — NSAID <15 days a month, Triptan < 10 days a month
31
Q
HA Rescue Treatment
-Antiemetic
A
- Early-onset nausea: metoclopramide, ondansetron
- Late onset Nausea and/or need sleep to end HA
- Promethazine (Phenergan)
- Prochlorperazine (Compazine) + diphenhydramine (Benadryl)
32
Q
Rescue Treatment w/ NSAIDS
A
- Ibuprofen (Motrin, Advil) — 10mg/kg/day Max 40mg/kg/day
- Naproxen (Aleve) — 5-7mg/kg/dose, Max 1000mg/day —Available as liquid Rx 125/5mls
- Diclofenac sodium (Cambia) — 2-3mg/kg/day / 2-4 times a day, Max 200mg/day
- Ketorolac (Torodol) — 10 mg every 4-6 hrs orally, Max 40 mg/day
33
Q
HA Rescue Treatment
-Triptans
A
- Rizatriptan (Maxalt) — Fastest acting Triptan
34
Q
HA management Prevention
A
- Amitriptyline and Topiramate — MOST COMMONLY prescribed agents
- Goal is 50% change over 3 months
35
Q
HA Prevention Indications
A
- HA’s significantly impact quality of life and daily routine
- Frequent HAs
- >/=4 migraines/month or >/=8 headache days/month - Infrequent but prolonged headaches
- Sub-optimal rescue treatment
- Neuroprotection — Migraine w/ aura can be a risk for CVA
- Patient/family preference
- Use S/E as a pro
36
Q
Headache Prophylaxis
-General principles
A
- Low and slow
- Adequate trial of 3 months necessary to determine efficacy
- Set realistic goals
- 50% change over 3 months
- Improved response to rescue Tx
- migraine =4/month, functional w/in about an hour
- NOT complete headache freedoms, BUT improved QOL
37
Q
Focal Seizure Testing
A
- Always get MRI if pt has focal seizure
