Paediatric neurology (Intro & Headaches)

Question 1

What types of pathologies can affect a childs brain?

Answer 1

Congenital anomolies

Neurogenetic diseases & syndromes

Neurometabolic diseases & syndromes

Acquired pathologies - infections, tumours etc

Question 2

Neurological examination of a child involves lots of expected stuff like looking at their appearance, head size and gait

One of the aspects is looking at the skin - why is this?

Answer 2

In embryology - skin and nervous system develop closely

Thus ‘neurocutaneous’ markers can appear on the skin and indicate neuro stuff

Example - cafe-au-lait spots can indicate neurofibromatosis type 1

Also things like meningococcal meningitis causes spots etc

Question 3

How common are headaches in children?

What are the different patterns of headaches that a child may experience?

Answer 3

In about 40% children by age 7, 75% of children by age 15

Patterns:

• Isolated acute
• Recurrent acute
• Persistent
• Chronic progressive
• Chronic non-progressive

Question 4

What are the key examination points for a child presenting with a headache?

Answer 4

Growth parameters, OFC, BP

Sinuses, teeth, (+ears?)

Visual acuity, visual fields, eye movements

Fundoscopy

Auscultate for Cranial bruit

Full neurological examination

Cognitive and emotional status

Question 5

What are the 2 main headaches in children

Answer 5

Migraines & tension headaches

Question 6

Describe the typical history of a child’s migraine

Answer 6

Fairly acute headaches - may be recurrent - often described as:

• Hemicranial
• Throbbing / pulsatile nature
• Associated w/ abdo pain, nausea & vomiting
• +/- aura

Question 7

On the topic of migraine - what are the potential:

a) features of aura
b) things noticed by parents
c) aggravating factors
d) relieving factors
e) family history links

Answer 7

a) Aura:

• visual disturbances, paraesthesia, weakness
• experienced before, during or after attack

b) Things noticed by parents - Pallor, hx of tired, stressed
c) Aggravating factors - bright light, noise
d) Relieving factors - quiet, dark room, rest, sleep
e) Family history - often positive FH

Question 8

Compare a tension headache to a migraine

Answer 8

Tension headaches are more diffuse & symmetrical - with a band-like distribution

They also tend to happen in older children

They are also more constant in nature - like a persistent ache

Question 9

What are indicators in a history that a headache is due to raised intracranial pressure ICP?

Answer 9

Pain aggravted by activities that raise ICP - coughing, straining on the toilet, bending over

Waking from sleep +/- vomiting

Releived during the day (when in upright position)

Question 10

What are the indicators in a history that a headache is due to analgesic overuse?

Answer 10

Headache is back before allowed to use another dose

Paracetamol/ NSAIDs

Particular problem with compound analgesics eg. Cocodamol

Question 11

What are the different indications for neuroimaging?

Answer 11

Features of cerebellar dysfunction

Features of raised ICP

New focal neurological deficit - eg new squint

Seizures, esp focal

Personality change

Unexplained deterioration of school work

Question 12

One of the indications for neuroimaging is cerebellar dysfunction

What are features of cerebellar dysfunction?

Answer 12

Abnormal finger-nose pointing in neuro exam

Ataxia - ie hx of tripping and falling

Question 13

How are migraines managed in children?

Answer 13

Acute attack:

• paracetamol or ibuprofen
• triptans - v effective in the older child

Prevention (if happen at least 1/week):

• Propranolol - best
• alternatives - pizotifen, amitryptiline, topirimate, valproate

Question 14

How are tension type headaches (TTHs) managed in children?

Answer 14

General:

• reassurance of no sinister cause - and management of physical, psychological or emotional factors

Acute:

• Simple analgesics - paracetamol/ibuprofen

Prevention (if recurrent):

• Amitryptiline