HeadachesHeadachesPractical approachPractical approach

Dr MaltbyDr Maltby

Chronic Headache Chronic Headache

MigraineMigraineTension headaches/chronic daily headachesTension headaches/chronic daily headachesTeeth/Nocturnal grindingTeeth/Nocturnal grindingSinus congestionSinus congestionVisualVisualSleep apnoeaSleep apnoeaBenign Occipital EpilepsyBenign Occipital EpilepsyBIHBIHRaised intracranial pressure Raised intracranial pressure

When to scanWhen to scan

Very young childrenVery young childrenChange in the character of headachesChange in the character of headachesHistory suggestive of raised ICPHistory suggestive of raised ICPFocal neurological SignsFocal neurological SignsPapillodema – not optic detrusum Papillodema – not optic detrusum Headache with erratic vomitingHeadache with erratic vomitingFH or anxiety of IC lesionFH or anxiety of IC lesionBIH with optic nerve viewsBIH with optic nerve views

Mausley StudyMausley Study

Very old study 1998Very old study 1998Looked at children with CNS tumours Looked at children with CNS tumours mode of referral and the symptomsmode of referral and the symptomsMajority DID NOT have symptoms Majority DID NOT have symptoms classically of raised ICPclassically of raised ICPMajority DID NOT have focal neurologyMajority DID NOT have focal neurologyMajority had frequently been seen by GP Majority had frequently been seen by GP paediatricians and even a paediatric paediatricians and even a paediatric neurologist neurologist

ConclusionsConclusions

Falsely reassured by normal examinationFalsely reassured by normal examination

Signs of ICP are great but don’t helpSigns of ICP are great but don’t help

Change in character in under 5Change in character in under 5

School failure in over 5 School failure in over 5

MigraineMigraine

Episodes headaches relief with sleepEpisodes headaches relief with sleepVomitingVomitingVisual disturbance- specificVisual disturbance- specificPallorPallorFH FH Motion sicknessMotion sicknessNeurological symptoms vary Neurological symptoms vary Between times pain freeBetween times pain free

ManagementManagement

Examination normalExamination normal

Scan if under 5Scan if under 5

Advice about treating the acute attackAdvice about treating the acute attack

Isolating triggers avoidance if possibleIsolating triggers avoidance if possible

Multiple Multiple

TriggersTriggers

Dietary – dairy, citrus, tomatoes, Dietary – dairy, citrus, tomatoes, blackcurrant, fizzy drinks – J2O blackcurrant, fizzy drinks – J2O

Sleep – excessive weekend lyins or sleep Sleep – excessive weekend lyins or sleep oversovers

Excitement Excitement

Stressed out Stressed out

Busy life Busy life

Busy lives Busy lives

After school clubsAfter school clubsSibs after school clubsSibs after school clubsWeekend activityWeekend activitySleep oversSleep oversHome work – plans/supervisionHome work – plans/supervisionFriendshipsFriendshipsSport activitiesSport activitiesRushing mothersRushing mothers

Management of acute attackManagement of acute attack

Immediate analgesia- emergency protocol Immediate analgesia- emergency protocol

Write to the school for their supportWrite to the school for their support

Ibrufen, MigraleveIbrufen, Migraleve

If vomiting MigraleveIf vomiting Migraleve

Very rare to need SumitryptinVery rare to need Sumitryptin

Monitor school attendance maybe late Monitor school attendance maybe late attendance better than noneattendance better than none

Preventive managementPreventive management

Depend on the frequency school Depend on the frequency school attendanceattendance

Diet exclusionDiet exclusion

Recognise triggersRecognise triggers

PziotifenPziotifen

Others treatments- Topiramate, Others treatments- Topiramate, Epilum,Gabapentin, Amitriptyline Epilum,Gabapentin, Amitriptyline

Chronic daily headacheChronic daily headache

TeenagersTeenagers

High achieversHigh achievers

Driven from within not by school/parentsDriven from within not by school/parents

Lots of mates- squabble or miss no matesLots of mates- squabble or miss no mates

Area of stress in family homeArea of stress in family home

Not helped by analgesiaNot helped by analgesia

Never wake with headache but have it at nightNever wake with headache but have it at night

Most difficult to manageMost difficult to manage

ManagementManagementGeneral adviceGeneral advice

Fluid intakeFluid intakeRegular meals- diet restrictionsRegular meals- diet restrictionsRegular exerciseRegular exerciseRegular sleep patterns – lying in!Regular sleep patterns – lying in!TV and computer usageTV and computer usageAnalgesia usageAnalgesia usageNormalising life Normalising life After school clubs and in sibsAfter school clubs and in sibsAvoid asking” do you have a headache”Avoid asking” do you have a headache”Family attitude to illness Family attitude to illness

ExplanationExplanation

Stressy teenagers learn to relax- pilartesStressy teenagers learn to relax- pilartes

Advice about studying Advice about studying

Driven from within Driven from within

Learn to live with it Learn to live with it

Treatment strategiesTreatment strategies

Dietary exclusion – formally not by diary Dietary exclusion – formally not by diary Diary – shocking what they eatDiary – shocking what they eatExclude for 6 weeks:Exclude for 6 weeks:

Diary productsDiary products Citrus/Apples in any formCitrus/Apples in any form Tomatoes and ketchupTomatoes and ketchup Fizzy drinksFizzy drinks Blackcurrant drinksBlackcurrant drinks ChocolateChocolate Marmite Marmite Anything else you can think of especially if the love themAnything else you can think of especially if the love them

Replace one thing every 4 days if there was a responseReplace one thing every 4 days if there was a response

MedicationMedication

Diet fails or the child cheats or refusesDiet fails or the child cheats or refuses

Explanation of pain modification the pain is Explanation of pain modification the pain is there but the response is different there but the response is different

Trail of Pziotfen ONLY at night – for at Trail of Pziotfen ONLY at night – for at least 6 weeksleast 6 weeks

TopiramateTopiramate

GabapentinGabapentin

Epilum Epilum

Alternative treatementsAlternative treatements

ButterburButterbur

Migraine support groupMigraine support group

Headache clinicsHeadache clinics

CAMSCAMS

BIHBIH

DO not diagnosis this unless confirmed DO not diagnosis this unless confirmed papillodeama and optic nerve swelling on papillodeama and optic nerve swelling on MRIMRI

Reproducible reduction in visual acuityReproducible reduction in visual acuity

Formal visual fields assessment is poor Formal visual fields assessment is poor even in teenagereven in teenager

Child has a risk factor – obesity and Child has a risk factor – obesity and tetracycline usage tetracycline usage

DiagnosisDiagnosis

Raised pressure on opening at LPRaised pressure on opening at LP

Not under GA straightened legsNot under GA straightened legs

Pressure above 20Pressure above 20

Therapeutic and diagnostic procedure so Therapeutic and diagnostic procedure so reduce pressure to 20 if over 40 then reduce pressure to 20 if over 40 then halve ithalve it

Dramatic response to LP in terms of Dramatic response to LP in terms of treatment treatment

PitfallsPitfalls

Repeated LPRepeated LP

Refusal to allow it without a GARefusal to allow it without a GA

Symptoms from LP confuse the pictureSymptoms from LP confuse the picture

Side effects from the DiamoxSide effects from the Diamox

Evidence that evolves residual chronic Evidence that evolves residual chronic daily headachedaily headache

Bolt monitoringBolt monitoring

Questions?Questions?

Hard work Hard work

Fits Faints and Funny turns

NoahNoah

18 months18 monthsThree episodes when his mother says he is found on the floor Three episodes when his mother says he is found on the floor unresponsive floor and jerks lasts about 30mins but father thinks unresponsive floor and jerks lasts about 30mins but father thinks less.less.Preceded by a cryPreceded by a cryAfter he appears confused and inconsolable After he appears confused and inconsolable EEG performed by the SHO after being seen in A/E- normal EEG performed by the SHO after being seen in A/E- normal ECG normal QTc 0.42secECG normal QTc 0.42sec24hr ECG normal24hr ECG normalFH father used to do this as a child and was treated with PhenytoinFH father used to do this as a child and was treated with PhenytoinComes to discuss if they should give a trail of anticonvulsantComes to discuss if they should give a trail of anticonvulsant

EllieEllie

12 years of age 12 years of age C/O fit at school C/O fit at school Fat lasting 5 minutes witness by the first aider (whose sister used to Fat lasting 5 minutes witness by the first aider (whose sister used to have fits)have fits)Called 999 by the maths teacher was sick and confused afterwards Called 999 by the maths teacher was sick and confused afterwards In A/E now feeling better fully conscious a slight headache In A/E now feeling better fully conscious a slight headache B?S by paramedics 6.5B?S by paramedics 6.5PMH febrile convulsion resulting in an PICU admission for 24 hours PMH febrile convulsion resulting in an PICU admission for 24 hours given rectal diazepam  that mother still carriesgiven rectal diazepam  that mother still carriesFH Mother has epilepsy on TegretolFH Mother has epilepsy on TegretolExam normal Exam normal No focal signs to find No focal signs to find One café au lait  spot One café au lait  spot Referred to you asking if they could attend first fit clinic and an EEG Referred to you asking if they could attend first fit clinic and an EEG has been organised has been organised

Part two - clinicPart two - clinic

Further episode occurred during home tec Further episode occurred during home tec and at home witness by her older sisterand at home witness by her older sister

School refuse to have her back unless School refuse to have her back unless “some things is done”“some things is done”

Mother is sleeping in her bedroom on the Mother is sleeping in her bedroom on the floorfloor

EEG –non specfic changes has occasional EEG –non specfic changes has occasional spikesspikes

MAXMAX

4 years of age- 8 daily episodes cries sits down goes rigid eyes roll 4 years of age- 8 daily episodes cries sits down goes rigid eyes roll back lasting 2mins then confused afterwards for a bout 30mins.back lasting 2mins then confused afterwards for a bout 30mins.Described as paleDescribed as paleMax says he feels dizzy before hand.Max says he feels dizzy before hand.Neurodevelopmental normalNeurodevelopmental normalNo other reported problems – absence episodes reported by the No other reported problems – absence episodes reported by the nursery but not noted at home nursery but not noted at home PMH – sinus bradycardia as neonate seen by Cardiologist at GOS PMH – sinus bradycardia as neonate seen by Cardiologist at GOS happy with him happy with him Examination normal HR 70 nil else Examination normal HR 70 nil else Echo normal Echo normal ECG normalECG normalNormal QTc -0.44secNormal QTc -0.44sec 24hour tape mum went to anyway not cancelled24hour tape mum went to anyway not cancelled

Differential diagnosis of a Differential diagnosis of a seizureseizure

Syncope-         VasovagalSyncope-         Vasovagal                                                Cardiac causes- cardiomyopathy/prolonged QTcCardiac causes- cardiomyopathy/prolonged QTcBreath holdingBreath holdingReflex anoxic seizures/ Reflex anoxic syncopeReflex anoxic seizures/ Reflex anoxic syncopePsuedo sezuiresPsuedo sezuiresEmotional syncopeEmotional syncopeValsalva/ constipationValsalva/ constipationStereotypical behavioursStereotypical behavioursTics Tics Gratification habitsGratification habitsBasilar migraineBasilar migraineParoxysmal spasmodic torticollisParoxysmal spasmodic torticollisBenign paroxysmal vertigoBenign paroxysmal vertigo

TAKE A HISTORY THE EVENT AND THE TAKE A HISTORY THE EVENT AND THE RUN UP AND AFTER.RUN UP AND AFTER.

If your not sure adopt watchful waiting DO If your not sure adopt watchful waiting DO NOT order an EEG unless you think it will NOT order an EEG unless you think it will give you information and interoperated the give you information and interoperated the information with the clinical caseinformation with the clinical case

Give advice Give advice

1. What are the risk for a reoccurrence after one seizure? After two seizures?2. What should you tell them to do at school?3. Whats the advice regarding swimming?4. Whats the advice about sleeping arrangements?5. Whats to do about TV and computer games?6. Any other advice?7. You reg wants to give them Midazolam prescribe it?

Is the episode a seizures?Is the episode a seizures?

What’s the cause of the seizure?What’s the cause of the seizure?

Is this epilepsy?Is this epilepsy?

What is the cause of the epilepsy? ---------- What is the cause of the epilepsy? ---------- NOW think EEGNOW think EEG

Classify epilepsy into a syndrome?Classify epilepsy into a syndrome?

www.stars.org.ukwww.stars.org.uk

www.epilepsy.org.uk/infowww.epilepsy.org.uk/info

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