Neurology: Breath Holding, Headache Flashcards
What is a breath holding spell?
Involuntary episodes during which a child holds their breath, usually triggered by something upsetting or scaring them.
The child has no control over the breath holding spells.
They are not harmful in the long term, do not lead to epilepsy and most children outgrow them by 4 or 5 years.
What age do breath holding spells typically occur between?
6 - 18 months
What are breath holding spells often divided into?
1) cyanotic breath holding spells
2) pallid breath holding spells (AKA reflex anoxic seizures)
When do cyanotic breath holding spells occur?
When the child is really upset, worked up and crying.
After letting out a long cry they stop breathing, become cyanotic and lose consciousness.
Within a minute they regain consciousness and start breathing.
They can be a bit tired and lethargic after an episode.
When do reflex anoxic seizures occur?
When the child is startled.
When happens in a reflex anoxic seizure?
The vagus nerve sends strong signals to the heart that cause it to stop beating.
The child will suddenly go pale, lose consciousness and may start to have some seizure-like muscle twitching.
Within 30 seconds the heart restarts and the child becomes conscious again.
Management of breath holding spells?
After excluding other pathology and making a diagnosis, educating and reassuring parents about breath holding spells is the key to management.
What condition have breath holding spells been linked with?
Iron deficiency anaemia
What is the most common cause of 1ary headache in children?
Migraine without aura
What are some causes of headaches in children?
- Tension headaches
- Migraines
- Ear, nose & throat infection
- Analgesic headache
- Problems with vision
- Raised ICP
- Brain tumours
- Meningitis
- Encephalitis
- Carbon monoxide poisoning
Presentation of tension headaches?
- Band like pattern around head
- Mild ache/pain/pressure
- Come on and resolve gradually
- Typically symmetrical
How can tension headaches present in younger children?
Non-specific symptoms:
- Become quiet
- Stop playing
- Turn pale
- Become tired.
They tend to resolve more quickly in children compared with adults, often within 30 minutes.
What are some triggers for tension headaches in children?
1) Stress, fear or discomfort
2) Skipping meals
3) Dehydration
4) Infection
Management of tension headaches in children?
Reassurance, analgesia, regular meals, avoiding dehydration and reducing stress.
What are some different types of migraines?
1) Migraine without aura
2) Migraine with aura
3) Silent migraine (migraine with aura but without a headache)
4) Hemiplegic migraine
5) Abdominal migraine
Presentation of a migraine?
- Unilateral
- More severe
- Throbbing in nature
- Take longer to resolve
Often associated with:
- Visual aura
- Photophobia and phonophobia
- N&V
- Abdominal pain
Management of acute migraine in children?
1) Rest, fluids and low stimulus environment
2) Paracetamol
3) Ibuprofen
4) Sumatriptan (nasal spray) if ≥12 y/o
5) Antiemetics, such as domperidone (unless contraindicated)
Note - ibuprofen is thought to be more effective than paracetamol for paediatric migraine.
What is the only triptan that has proven efficacy for acute management of migraine?
Sumatriptan
From what age can sumatriptan be used in the acute management of migraine?
≥12 y/o –> nasal spray
Note - ORAL triptans are not currently licensed in people < 18 years
Side effects of triptans?
Tingling, heat and heaviness/pressure sensations
When can migraine prophylaxis be considered in children?
Where the migraines are having a significant impact on life, for example frequent attacks or missing school, prophylactic treatment can be tried to reduce the frequency and severity of the migraines.
What are the 2 options for migraine prophylaxis in children?
Note - Preventive treatment for children with migraine should not be initiated in primary care — seek specialist advice.
1) Propranolol
2) Topiramate
Who should propanolol for migraine prophylaxis be avoided in?
Asthma
Who should topiramate for migraine prophylaxis be avoided in?
Girls with child bearing potential need highly effective contraception as it is very teratogenic.
What are some common triggers for migraine?
- stress
- hormonal changes e.g. menstrual cycle, menopause
- sleep disturbances e.g., insomnia, irregular sleep patterns
- dietary factors e.g. caffeine, alcohol
- sensory stimuli e.g. bright lights, loud noises, strong odours
- medications e.g. vasodilators, oral contraceptives
What are some migraine aura symptoms are atypical and may prompt further investigation/referral?
1) motor weakness
2) double vision
3) visual symptoms affecting only one eye
4) poor balance
5) decreased level of consciousness.
What are the 3 options for migraine prophylaxis in adukts?
1) propranolol
2) topiramate
3) amitriptyline
What is an abdominal migraine?
Episodes of central abdominal pain lasting more than 1 hour.
Examination will be normal.
These are more common in young children. This may occur in young children before they develop traditional migraines as they get older.
Features of an abdominal migraine?
- Central abdo pain >1 hour
May be associated with:
- Nausea and vomiting
- Anorexia
- Headache
- Pallor
When a patient presents with possible migraines, what should you ask about regarding their childhood?
Ask about recurrent central abdominal pain as a child.
They may have a history of abdominal migraine that started before the headaches.
What infections can cause headaches in children?
1) Viral URTIs
2) Otitis media
3) Sinusitis
4) Tonsilitis
The headache should resolve along with the infection.
How does sinusitis typically present?
- headache
- facial pain behind the nose, forehead and eyes
- often tenderness over the affected sinuses, which helps to establish the diagnosis.
Sinusitis usually resolves within 2 – 3 weeks. Most sinusitis is viral.
