Paediatric Neurology - The Child with Headache Flashcards

1
Q

•Child neurology is dynamic:

The brain continues to ____

Brain functions ______

Neurodevelopment continue to ________

Static lesion produce _________ features

A

grow

evolve

progress

evolving

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2
Q

there is Extensive pathology in paediatric neurology sych as what?

A

Congenital anomalies - part of brain not formed, developed, abnormally developed

Neurogenetic diseases and syndromes - downs syndrome, seizures

Neurometabolic diseases and syndromes - can cause structural problems

Acquired : Infection, Ischaemia, Trauma, Tumour - trauma, drugs

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3
Q

The neurological consultation in childhood - what information is required?

A
  • History taking: interactive
  • Hear what was said, not what you thought was said
  • Avoid quasi-medical language
  • Time course of symptoms crucial
  • Distinguishing static from slowly progressive symptoms can be challenging
  • Perinatal, developmental, family history
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4
Q

what information is required to gather as part of the Developmental history?

A
  • Motor milestones: gross and fine motor skills
  • Speech and language development
  • Early cognitive development
  • Play esp. symbolic play and social behaviour
  • Self-help skills
  • Vision and Hearing assessment

Global delay – if delay in 2 or more domains

May only have a delay in an isolated domain

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5
Q

What is involved in a Neurological examination in childhood?

A
  • Opportunistic approach and observation skills (Watching the child gives you lots of info of the integrity of the nervous system)
  • Appearance
  • Gait
  • Head size
  • Skin findings
  • Real world examination (depends on age)
  • Synthesis of history and clinical findings into a differential diagnosis and investigation plan
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6
Q

how common are paediatric neurological problems?

A
  • 10% of primary care consultations for children
  • 25% of hospitalised children
  • Migraine 7.7% of children 10-17
  • Traumatic Brain Injury: 180-300/ 100,000 children
  • Tourette syndrome: 1% of all children with high frequency in ADHD and OCD
  • Epilepsy: 0.7% of all children, 1/3 will have intractable epilepsy (difficult to control)
  • Brain tumours: second most common cancer in children
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7
Q

Headache disorders:

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

Most parents who seek help for a child with headaches are looking for reassurance that the headache is not due to a serious cause

Clinical evalutation: what are the 4 different types?

A

Isolated acute

Recurrent acute (completely asymptomatic in-between)

Chronic progressive

Chronic non-progressive

Acute and chronic progressive needs some investigation

Acute recurrent – may be primary headache like migraine

Chronic nonprogressive is more common that chronic progressive – sore head for 15/30 days of month, may be fluctuating level of headache

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8
Q

Recurrent or chronic headache history - what should you ask and find out?

A
  • Is there more than 1 type of headache?
  • Typical episode:
  • Any warning?
  • Location?
  • Severity?
  • Duration?
  • Frequency?
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9
Q

Examination is directed at making sure there is no secondary cause for headache and headache described is a primary headache

what is done on a headache examination?

A
  • Growth parameters (plot on growth chart) (Growth may be affected due to secondary headache), OFC (may indicate intracranial pathology – tumour, hydrocephalus), BP (hypertension can cause headache or there may be intracranial pathology)
  • Sinuses, teeth (may point to a referred headache), visual acuity
  • Fundoscopy
  • Visual fields (craniopharyngioma)
  • Cranial bruit (may indicate intracranial pathology again)
  • Focal neurological signs
  • Cognitive and emotional status
  • The diagnosis of headache etiology is clinical
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10
Q

what are pointers to childhood migraine?

A
  • Associated abdominal pain, nausea, vomiting
  • Focal symptoms/signs before, during, after attack: Visual disturbance, paresthesia, weakness
  • ‘Pallor’
  • Aggravated by bright light/noise
  • Relation to fatigue/stress
  • Helped by sleep/rest/dark, quiet room
  • Family history often positive

Examination is normal in primary headache normally so tells you you either dealing with migraine or tension type headache

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11
Q

Migraine vs Tension headache - what is the difference?

A

Important to categorize as helps management with right treatment choices

In adults hemicranial pain but in children often all over or frontal so not as obvious

Any preceding aura

Migraines can occur at a very young age (4/5 years old)

Tension type tends to come on later in life

Often featureless headache

Few qualifying features, no localizing features

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12
Q

what are some pointers to Raised intracranial pressure?

A
  • Aggravated by activities that raise ICP eg. Coughing, straining at stool, bending
  • Woken from sleep with headache +/- vomiting
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13
Q

what are some pointers to Analgesic overuse headache?

A
  • Headache is back before allowed to use another dose
  • Paracetamol/NSAIDs
  • Particular problem with compound analgesics eg. Cocodamol
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14
Q

what are Indications for neuroimaging?

Headaches common so cant afford to image everyone

Never want to miss intracranial pathology

A
  • Features of cerebellar dysfunction
  • Features of raised intracranial pressure (waking up at night with headache and vomiting and headache is relieved through the day when they are in the up right position)
  • New focal neurological deficit eg. new squint
  • Seizures, esp focal
  • Personality change
  • Unexplained deterioration of school work
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15
Q

what is the management of a migraine?

A
  • Acute attack: effective pain relief, triptans
  • Preventative (at least 1/week): Pizotifen, Propranolol, Amitryptyline, Topiramate, Valproate

Pain relief may just be simple analgesia like paracetamol or ibuprofen

Triptans in older children

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16
Q

what is the management of a TTH?

A
  • Aim at reassurance: no sinister cause (main objective is to look at what underlying cause propagate the headache)
  • Multidisciplinary management
  • Attention to underlying chronic physical, psychological or emotional problems
  • Acute attacks: simple analgesia
  • Prevention: Amitryptiline
  • Discourage analgesics in chronic TTH

Often seen analgesia overuse