The child or adolescent with a headache

Question 1

Etiology

Answer 1

Tension headache Migraine +ICP Meningitis SAH Cluster Eye strain Sinusitis Hypertension Dental caries Analgesic headache

Question 2

Important history including red flags

Answer 2

Description of HA->SOCRATES Family history migraines Aura/prodrome, throbbing Worse in morning, leaning forward, wakes from sleep, vomiting->ICP Photophobia, neck stiffness, fever->meningitis Nasal congestion pain in teeth/ears->Sinusitis HEADSS!! Red flags: Acute and severe Progressive and chronic Focal neurology Aged <3 yo HA/Vomiting on waking Consistent location of recurrent headaches Presence of VP shunt Hypertension

Question 3

Important examination

Answer 3

ABC, Vitals->Record blood pressure Are they bradycardia General examination->rash, whole body, temperature, irritability, ENT Examine fundi->papilloedema Are their focal neurological signs: a. cerebellar: nystagmus, ataxia, intention tremor b. infratentorial: cranial nerve palsies c. cerebral: focal seizures, spasticity d. pituitary: endocrine dysfunction, visual field defects Look for evidence of dental caries, sinus tenderness, audible cranial bruits

Question 4

When is CT or MRI indicated

Answer 4

Evidence of +ICP Localising neurological signs Headache persisting and not responding to normal medication/analgesia Meningism (consider LP) +Frequency of undiagnosed headaches

Question 5

Most common 3 causes of HA in older childre

Answer 5

Viral infection Local infection (sinusitis) Related to tension Migraine

Question 6

Concerning features in HA (9)

Answer 6

Acute onset Worse on lying down Vomiting Unilateral Developmental regression or personality change HTN Papilloedema +head circumference Focal neurological signs

Question 7

Typical onset of migraine

Answer 7

Late childhood and adolescence

Question 8

Atypical presentation of migraine which can occur in children

Answer 8

Bilateral Without aura No vomiting

Question 9

How is migraine diagnosed

Answer 9

Clinically Episodic Perfectly well in between Aura Nausea Throbbing +ve FHx Impaired normal function during attacks Lasts 1-72 hours

Question 10

Assessment tools

Answer 10

1. Headache patterns 2. HEADSS 3. International headache society: guideline

Question 11

Management of simple headache

Answer 11

Environmental adjustments Paracetamol 15mg/kg PO Consider ondansetron in active vomiting

Question 12

Management of migraine and follow up

Answer 12

<12 yo 1. Enviromental 2. Paraceamol 3. Ibuprofen 10mg/kg 4. Chlorpromazine 0.15mg/kg in IL N saline over 1 hour, caution hypotension

>12 yo 1. Environmental 2. Paracetamol 15mg/kg 3. Aspirin 1g PO 4. Sumitriptan->nasal, may repeat dose once 5. Chlorpromazine IV in 1L N saline

Refer to specialist if: 1-2 HA/week, disabling, missed >2/52 school aim to reduce to frequency <3/month and decrease disability

GP mainstay of ongoing management

PhysiotherpY, MH Review, headache diary

Question 13

General advice for migraine

Answer 13

Early treatment important Limit treatment with meds to 3 times/week to prevent overuse/rebound Avoid missing school Reassurance no serious pathology Hydration Avoid caffeine and alcohol Don’t miss meals Good sleep hygeine Nutrition Exercise Adress stressors

Question 14

What to include in a headache diary

Answer 14

when the headache started how long it lasted which part of their head hurt if there were any other symptoms how bad it was on a scale of one (mild) to 10 (very bad) what seemed to trigger it what, if anything, helped it to go away the time they went to bed the night before what time the headache stopped if they missed any school because of the headache.

Question 15

Other information to tell parents when to come in with child with a headache

Answer 15

1. Head injury - headaches from a recent head injury should be checked right away, especially if your child was knocked out (lost consciousness) by the injury. 2. Seizures/convulsions - any headaches associated with seizures or fainting need immediate attention. 3. Frequency - your child gets more than one headache each week. 4. Degree of pain - headache pain is severe and prevents your child from doing activities they want to do or going to school. 5. Time of attack - headaches that wake your child from sleep or occur in the early morning or when they wake up. 6. Visual difficulties - headaches that cause blurred vision, eye spots, or other visual changes. 7. Other associated symptoms - if fever, vomiting, stiff neck, toothache or jaw pain accompany your child’s headache, they may need an examination and some tests (such as an X-ray).

Question 16

Common childhood brain tumors which may cause HA and associated signs

Answer 16

1. meduloblastoma (cerebellar signs: poor coordination and gait disturbance) 2. craniopharyngiomas (abnormal visual acuity and fields, extraocular eye movements, poor growth).

Question 17

When asking about school, what should you always ask about that may +headache

Answer 17

Bullying

Question 18

Explaining migraine to parents

Answer 18

1. Causes: being tired, bright lights, loud noises, relaxation, muscle tension, alcohol, missing meals, smoking, caffeine, periods, OCPS
2. No cure, avoid triggers. Aim to control child symptom’s and prevent further migraines.
3. Medication is best used when the symptoms
4. Regular meals and sleep patterns are very important.
5. Resting in a quiet, dark room, and may reduce how severe the symptoms are when a headache happens.
6. Paracetamol may reduce pain if taken at the beginning of the headache.
7. Relaxation techniques may help some children
8. For those children with very frequent and disabling headaches, referral to a specialist may be needed and may start on preventative medication

Question 19

Explaining tension headaches to parents

Answer 19

1. Feels like a tight band
2. Stiffenening or tensing of muscles around the head or neck
3. Dull, aching, usually on both sides.
4. Pressure/stresses at school or home, too much to do, anxiety, depression can cause it.
5. Can take ibuprofen / paracetamol for occasional.
6. Caution rebound with repetitive