Paediatric Neurology - The Child with Headache Flashcards
•Child neurology is dynamic:
The brain continues to ____
Brain functions ______
Neurodevelopment continue to ________
Static lesion produce _________ features
grow
evolve
progress
evolving
there is Extensive pathology in paediatric neurology sych as what?
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
The neurological consultation in childhood - what information is required?
- 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
what information is required to gather as part of the Developmental history?
- 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
What is involved in a Neurological examination in childhood?
- 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
how common are paediatric neurological problems?
- 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
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?
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
Recurrent or chronic headache history - what should you ask and find out?
- Is there more than 1 type of headache?
- Typical episode:
- Any warning?
- Location?
- Severity?
- Duration?
- Frequency?
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?
- 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
what are pointers to childhood migraine?
- 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
Migraine vs Tension headache - what is the difference?
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
what are some pointers to Raised intracranial pressure?
- Aggravated by activities that raise ICP eg. Coughing, straining at stool, bending
- Woken from sleep with headache +/- vomiting
what are some pointers to Analgesic overuse headache?
- Headache is back before allowed to use another dose
- Paracetamol/NSAIDs
- Particular problem with compound analgesics eg. Cocodamol
what are Indications for neuroimaging?
Headaches common so cant afford to image everyone
Never want to miss intracranial pathology
- 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
what is the management of a migraine?
- 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
