Headaches in Children - Cleveland Clinic · Usually not the case Incidence of Headaches 13% of boys...
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Headaches in Headaches in Children Children Manikum Moodley, MD, FRCP Manikum Moodley, MD, FRCP Section of Pediatric Neurology Section of Pediatric Neurology The Cleveland Clinic Foundation The Cleveland Clinic Foundation Children Children’ s Hospital s Hospital Introduction Introduction Headaches are common in children Headaches are common in children Most headaches are benign Most headaches are benign (migraine/tension/cluster) (migraine/tension/cluster) Cause of much parental anxiety as many Cause of much parental anxiety as many worry that their child worry that their child’ s headache is a sign s headache is a sign of brain of brain tumor tumor Usually not the case Usually not the case Incidence of Headaches Incidence of Headaches 13% of boys and 20% of girls 13% of boys and 20% of girls consult physicians for headache consult physicians for headache Migraine occurs in 5 Migraine occurs in 5-10% of 10% of children and 10 children and 10-20% of 20% of adolescents adolescents Classification of Headaches Classification of Headaches Primary Primary - migraine with or without aura migraine with or without aura - tension headache tension headache - cluster headache (rare) cluster headache (rare) - chronic daily headache chronic daily headache Secondary Secondary - trauma trauma - infection infection - brain brain tumor tumor - toxins/drugs toxins/drugs Clinical Presentation Clinical Presentation Acute Acute – influenza, sinusitis, meningitis, influenza, sinusitis, meningitis, head injury head injury Subacute Subacute – sinusitis, TBM sinusitis, TBM Chronic Progressive Chronic Progressive – brain brain tumor tumor Chronic non Chronic non- progressive progressive – chronic daily chronic daily headache headache
Transcript of Headaches in Children - Cleveland Clinic · Usually not the case Incidence of Headaches 13% of boys...
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Headaches in Headaches in ChildrenChildren
Manikum Moodley, MD, FRCPManikum Moodley, MD, FRCPSection of Pediatric NeurologySection of Pediatric NeurologyThe Cleveland Clinic FoundationThe Cleveland Clinic Foundation
ChildrenChildren’’s Hospitals Hospital
IntroductionIntroduction
Headaches are common in childrenHeadaches are common in childrenMost headaches are benign Most headaches are benign (migraine/tension/cluster)(migraine/tension/cluster)Cause of much parental anxiety as many Cause of much parental anxiety as many worry that their childworry that their child’’s headache is a sign s headache is a sign of brain of brain tumortumorUsually not the caseUsually not the case
Incidence of HeadachesIncidence of Headaches
13% of boys and 20% of girls 13% of boys and 20% of girls consult physicians for headacheconsult physicians for headache
Migraine occurs in 5Migraine occurs in 5--10% of 10% of children and 10children and 10--20% of 20% of adolescentsadolescents
Classification of HeadachesClassification of HeadachesPrimaryPrimary
-- migraine with or without auramigraine with or without aura-- tension headachetension headache-- cluster headache (rare)cluster headache (rare)-- chronic daily headachechronic daily headache
SecondarySecondary-- traumatrauma-- infectioninfection-- brain brain tumortumor-- toxins/drugstoxins/drugs
Clinical PresentationClinical Presentation
Acute Acute –– influenza, sinusitis, meningitis, influenza, sinusitis, meningitis, head injuryhead injurySubacuteSubacute –– sinusitis, TBMsinusitis, TBMChronic Progressive Chronic Progressive –– brain brain tumortumorChronic nonChronic non--progressive progressive –– chronic daily chronic daily headache headache
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Headache Types
Time (days)Time (days)00 3030 6060
Chronic Daily
Headache TypesHeadache TypesMixed/CoMixed/Co--morbidmorbid
Time (days)Time (days)00 3030 6060
Sym
ptom
sS
ympt
oms
Evaluation of HeadacheEvaluation of Headache
Detailed HistoryPhysical examinationNeurological examinationFormulate a differential diagnosisLaboratory testsTreatmentFollow-up
Post Surgical HeadachePost Surgical Headache
Poor documentation of post surgical Poor documentation of post surgical headaches in generalheadaches in generalHeadache following epilepsy surgery is Headache following epilepsy surgery is even less well documentedeven less well documentedPost craniotomy headache is relatively Post craniotomy headache is relatively well documented well documented –– a combination of a combination of tension type headache and site of injury tension type headache and site of injury headache overlying the surgical siteheadache overlying the surgical site
Headaches following epilepsy Headaches following epilepsy surgerysurgery
Acute Acute --together with other post operative together with other post operative symptoms which disappear spontaneouslysymptoms which disappear spontaneously
Chronic headaches are poorly Chronic headaches are poorly documenteddocumented
Migraine and tension type headaches Migraine and tension type headaches appear to be the commonestappear to be the commonest
Migraine is:Migraine is:
Almost always familialAlmost always familialEpisodic Episodic –– not dailynot dailyVariable symptoms:Variable symptoms:
FrequencyFrequency AuraAuraSeveritySeverity Nausea/VomitingNausea/VomitingLocationLocation PhonoPhono/Photophobia/PhotophobiaDurationDuration Neurological featuresNeurological features
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Migraine May Be:Migraine May Be:
Associated with Tension Headache.Associated with Tension Headache.Transformed into daily headachesTransformed into daily headachesRelated to head trauma/ surgeryRelated to head trauma/ surgeryRelated to stress/other triggersRelated to stress/other triggersRelated to illness/menses/diet Related to illness/menses/diet Associated with excessive school Associated with excessive school absencesabsences
HistoryHistoryRed FlagsRed Flags
First and worst headache everFirst and worst headache everOnset of a new type of headacheOnset of a new type of headacheChanges in a headache patternChanges in a headache patternPain that awakens the patientPain that awakens the patientPain caused by exertionPain caused by exertionPain unrelieved by initial treatmentPain unrelieved by initial treatmentPain with neurological symptomsPain with neurological symptoms
Physical ExaminationPhysical ExaminationRed FlagsRed Flags
Patient critically illPatient critically illSigns of head traumaSigns of head traumaNeck stiffnessNeck stiffnessLarge headLarge headHigh fever or the BP is raisedHigh fever or the BP is raisedSkin lesions as in NF1Skin lesions as in NF1
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Neurological ExaminationNeurological ExaminationRed FlagsRed Flags
Balance difficultyBalance difficultySeizures or abnormal movementsSeizures or abnormal movementsAltered level of consciousnessAltered level of consciousnessAbnormal eye movementsAbnormal eye movementsAbnormal Abnormal fundoscopicfundoscopic findingsfindingsAny neurologic abnormalitiesAny neurologic abnormalities
The GoodThe GoodA Case StudyA Case Study
An 11 An 11 y/oy/o girl has HA twice monthly, for the past 8 girl has HA twice monthly, for the past 8 months. There is no aura. She is pale. She goes to months. There is no aura. She is pale. She goes to her room, shuts off the lights and the television, and her room, shuts off the lights and the television, and refuses her usual snack. She is nauseated and refuses her usual snack. She is nauseated and sleeps. She is better in 3 hours. There are no sleeps. She is better in 3 hours. There are no neurological symptoms.neurological symptoms.Family history of migraine. She is an Family history of migraine. She is an ““AA”” student, student, does not miss school, and does not overuse OTC does not miss school, and does not overuse OTC medication. medication. Her physical and neurological examinations are Her physical and neurological examinations are normal.normal.
Good case Good case contdcontd
DiagnosisDiagnosis
Migraine without auraMigraine without aura
Migraine:Migraine:Goals of TreatmentGoals of Treatment
Reduction of headache severity, frequency, duration and disabilityAvoidance of acute/chronic excessive medicationImprovement of quality of life“Normalization”
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Migraine: TreatmentMigraine: Treatment
NoneNon pharmacologicalAcute – symptomaticAbortivePreventiveCombinations
Migraine:Migraine:NonNon--Pharmacological ApproachesPharmacological Approaches
Confident reassurancePatient/parent educationDiaryTrigger avoidance
stress/sleep/dietEnvironment
cool/quiet/dark/cold compressSchool attendanceRelaxation/biofeedback/counseling
Migraine:Migraine:Symptomatic TreatmentSymptomatic Treatment
Nausea and VomitingPromethazineMetaclopramideOndansetron
Migraine:Migraine:Symptomatic TreatmentSymptomatic Treatment
SedationDiphenhydramineCyproheptadineBenzodiazepine
Migraine:Migraine:Symptomatic TreatmentSymptomatic Treatment
PainNSAIDS
IbuprofenNaproxenAcetaminophen
Migraine:Migraine:Abortive TreatmentAbortive Treatment
None are FDA approved in children and adolescents
Ergotamine- DHETriptans
ImitrexZomig
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Migraine:Migraine:Symptomatic TreatmentSymptomatic Treatment
MAXIMS:Treat EarlyMaximum DosagesAvoid combinations
CaffeineSalicylatesBarbiturates
The BadThe BadA Case StudyA Case Study
A 15 A 15 y/oy/o girl has had girl has had frontotemporalfrontotemporal H/A for 5 years H/A for 5 years which are increasing in frequency, severity, and which are increasing in frequency, severity, and duration. H/A are no longer helped by duration. H/A are no longer helped by NSAIDsNSAIDs and and occur twice weekly in the early morning. occur twice weekly in the early morning. They are throbbing and accompanied by an aura and They are throbbing and accompanied by an aura and vomiting.vomiting.There is a positive FH of migraine. She overuses There is a positive FH of migraine. She overuses medication and has missed a lot of school.medication and has missed a lot of school.Her physical and neurological examinations are Her physical and neurological examinations are normal.normal.
Case Case contdcontd
DiagnosisDiagnosis
Severe migraine with auraSevere migraine with aura
Treatment OptionsTreatment Options
SymptomaticSymptomaticAbortive medicationAbortive medicationPreventive medicationPreventive medicationOtherOther
Migraine:Migraine:Consider Preventive TreatmentConsider Preventive Treatment
Significant interference with ADL / QOLSignificant interference with ADL / QOLHeadachesHeadaches
> 2 / week> 2 / week> 24 hours> 24 hoursUnresponsive to symptomatic/abortive Unresponsive to symptomatic/abortive medicationsmedicationsWith OTC overuseWith OTC overuse
Migraine:Migraine:Preventive TreatmentPreventive Treatment
None are FDA approved in children and None are FDA approved in children and adolescentsadolescents
AntiAnti--histamineshistamines-- periactinperiactinTricyclicTricyclic antidepressants antidepressants --elavilelavilAntiAnti--epileptics epileptics –– valproicvalproic acid, acid, topamaxtopamax
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The UglyThe UglyA Case StudyA Case Study
A 14 A 14 y/oy/o girl with known migraine is seen on an urgent girl with known migraine is seen on an urgent basis for a headache that has lasted 72 hours. Her usual basis for a headache that has lasted 72 hours. Her usual frequency is 2frequency is 2--3 per month, lasting 43 per month, lasting 4--6 hours and 6 hours and relieved by two doses of relieved by two doses of TriptansTriptans. . She has a viral illness and a low grade fever. She has She has a viral illness and a low grade fever. She has phonophono/photophobia and cannot keep anything down. /photophobia and cannot keep anything down. FH of migraine. She does not overuse OTC medications, FH of migraine. She does not overuse OTC medications, and has not missed school.and has not missed school.Gen exam shows dehydration. Gen exam shows dehydration. NeurologicNeurologic exam is normal.exam is normal.
“Rack Our Brains”
Differential DiagnosesDifferential Diagnoses
Illness plus migraineIllness plus migraineMeningitisMeningitisStatus Status migrainosusmigrainosusOtherOther
TestingTesting
Blood testsBlood testsCT/MRICT/MRISpinal tapSpinal tap
Case Case contdcontd
DiagnosisDiagnosis
Status Status MigrainosusMigrainosus
Treatment OptionsTreatment Options
Admit to infusion centerAdmit to infusion centerSedationSedationAntiemeticAntiemeticAnticonvulsants / DHEAnticonvulsants / DHESteroidsSteroids
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Treatment OptionsTreatment Options
Confident reassuranceConfident reassurancePatient / parent educationPatient / parent educationD/C OTC medicationsD/C OTC medicationsReturn to school is a mustReturn to school is a mustCounselingCounselingMedicationMedicationFollowFollow--upup
