Neurology: Breath Holding, Headache

Question 1

What is a breath holding spell?

Answer 1

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.

Question 2

What age do breath holding spells typically occur between?

Answer 2

6 - 18 months

Question 3

What are breath holding spells often divided into?

Answer 3

1) cyanotic breath holding spells

2) pallid breath holding spells (AKA reflex anoxic seizures)

Question 4

When do cyanotic breath holding spells occur?

Answer 4

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.

Question 5

When do reflex anoxic seizures occur?

Answer 5

When the child is startled.

Question 6

When happens in a reflex anoxic seizure?

Answer 6

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.

Question 7

Management of breath holding spells?

Answer 7

After excluding other pathology and making a diagnosis, educating and reassuring parents about breath holding spells is the key to management.

Question 8

What condition have breath holding spells been linked with?

Answer 8

Iron deficiency anaemia

Question 9

What is the most common cause of 1ary headache in children?

Answer 9

Migraine without aura

Question 10

What are some causes of headaches in children?

Answer 10

• Tension headaches
• Migraines
• Ear, nose & throat infection
• Analgesic headache
• Problems with vision
• Raised ICP
• Brain tumours
• Meningitis
• Encephalitis
• Carbon monoxide poisoning

Question 11

Presentation of tension headaches?

Answer 11

• Band like pattern around head
• Mild ache/pain/pressure
• Come on and resolve gradually
• Typically symmetrical

Question 12

How can tension headaches present in younger children?

Answer 12

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.

Question 13

What are some triggers for tension headaches in children?

Answer 13

1) Stress, fear or discomfort

2) Skipping meals

3) Dehydration

4) Infection

Question 14

Management of tension headaches in children?

Answer 14

Reassurance, analgesia, regular meals, avoiding dehydration and reducing stress.

Question 15

What are some different types of migraines?

Answer 15

1) Migraine without aura

2) Migraine with aura

3) Silent migraine (migraine with aura but without a headache)

4) Hemiplegic migraine

5) Abdominal migraine

Question 16

Presentation of a migraine?

Answer 16

• Unilateral
• More severe
• Throbbing in nature
• Take longer to resolve

Often associated with:
- Visual aura
- Photophobia and phonophobia
- N&V
- Abdominal pain

Question 17

Management of acute migraine in children?

Answer 17

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.

Question 18

What is the only triptan that has proven efficacy for acute management of migraine?

Answer 18

Sumatriptan

Question 19

From what age can sumatriptan be used in the acute management of migraine?

Answer 19

≥12 y/o –> nasal spray

Note - ORAL triptans are not currently licensed in people < 18 years

Question 20

Side effects of triptans?

Answer 20

Tingling, heat and heaviness/pressure sensations

Question 21

When can migraine prophylaxis be considered in children?

Answer 21

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.

Question 22

What are the 2 options for migraine prophylaxis in children?

Answer 22

Note - Preventive treatment for children with migraine should not be initiated in primary care — seek specialist advice.

1) Propranolol

2) Topiramate

Question 23

Who should propanolol for migraine prophylaxis be avoided in?

Answer 23

Asthma

Question 24

Who should topiramate for migraine prophylaxis be avoided in?

Answer 24

Girls with child bearing potential need highly effective contraception as it is very teratogenic.

Question 25

What are some common triggers for migraine?

Answer 25

• 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

Question 26

What are some migraine aura symptoms are atypical and may prompt further investigation/referral?

Answer 26

1) motor weakness

2) double vision

3) visual symptoms affecting only one eye

4) poor balance

5) decreased level of consciousness.

Question 27

What are the 3 options for migraine prophylaxis in adukts?

Answer 27

1) propranolol

2) topiramate

3) amitriptyline

Question 28

What is an abdominal migraine?

Answer 28

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.

Question 29

Features of an abdominal migraine?

Answer 29

• Central abdo pain >1 hour

May be associated with:
- Nausea and vomiting
- Anorexia
- Headache
- Pallor

Question 30

When a patient presents with possible migraines, what should you ask about regarding their childhood?

Answer 30

Ask about recurrent central abdominal pain as a child.

They may have a history of abdominal migraine that started before the headaches.

Question 31

What infections can cause headaches in children?

Answer 31

1) Viral URTIs

2) Otitis media

3) Sinusitis

4) Tonsilitis

The headache should resolve along with the infection.

Question 32

How does sinusitis typically present?

Answer 32

• 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.