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Pediatric Neurology Quick Talks

HeadacheMichael Babcock 

Summer 2013

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Scenario

• 7 yo boy

• Headaches for 4 months

• Headaches last 90 minutes• rabs the front of his head !hen it hurts

• Has about 1 headache a !eek" #omits !ith some of the headaches

• $ontinues to do !ell in school" no #ision com%laints

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Causes of headache

• &rimary

 '  Mi(raine

 '  )ension*ty%e '  $luster 

 '  &aro+ysmal hemicrania

 '  S,-$)

 '  )ri(eminal neural(ia .not

common in kids/ '  $hronic daily headache

• Secondary

 '  Medication o#eruse

.rebound/ '  headneck trauma

 '  ascular disorder ' SH"

M" #asculitis" $S)

 '  Hi(h $& o! $&

 '  )umor  '  nfection

• $-S

• 5ther infections

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History

• Headache ' 6uality" se#erity" location" laterality" onset" time course –

episodic and similar or progressive/changing

• ssociated sym%toms ' systemic sym%toms" fe#er" %ersonality chan(es"seiures

• &recedin( sym%toms ' aura" (radualra%id onset

• 8+acerbatin( features ' mi(raines !orse !ith acti#ity !orse !ith layin(

or nocturnal or !ith cou(hstrainin( ' si(ns of ele#ated $& !orse !ith

standin( ' si(ns of lo! $&:

• Medical history ' -;1" Stur(e*!eber" connecti#e tissue disorder" Sickle

cell" immunocom%romised:

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Exam

• itals ' fe#er" $& si(ns

• ood neurolo(ic e+am

 '  < ltered mental status '  bnormal eye mo#ements

 '  isual field testin(

 '  ;undosco%ic e+am

 '  ;ocal !eakness

 '  ,M- si(ns

 '  bnormal (ait

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Papilledema (normal to severe

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!ork"up• ma(in(

 '  )rauma

 '  ssociated seiures

 '  MS '  bnormal neurolo(ic e+am

 '  Historical features ' thundercla%

headache" %ersistently lateralied"

 %ro(ressi#e course" shunt" chan(e in

 %atternty%e" occi%ital headache

 '  Si(ns of ele#ated $&

 '  $onsiderations=

• no family history of mi(raine

• > 1 month of headache

• ?oun( a(e of onset

 '  &rior to &

• $S; analysis

 '  &seudotumor .H/

• ccurate recordin( of %ressure"

in lateral decub %osition must

e+tend 8@s:

 '  Menin(itis

• Menin(ismus

• ;e#er 

•  -e! seiures

• MS

• immunocom%romised

 '  SH

• )hundercla% headache

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#igraine

• ffects 7A of all children

• $auses 1*17 billion in lost %roducti#ity

• ccounts for 10 million %hysician #isitsyear in ,:S:

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#igraine Classification

• &ediatric mi(raine !ith aura

 '  t least 2 attacks fulfillin( B:

 '  t least 3 of the follo!in(• 5ne or more fully re#ersible aura

sym%tom indicatin( focal cortical

andor brainstem dysfunction

• at least 1 aura de#elo%in(

(radually o#er C 4 min or C 2

aura sym%toms occurrin( insuccession

•  -o auras lastin( C D0 minutes

• Headache no more than D0

minutes after aura

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#igraine treatment $ %ife"style modification

• Slee% ' don@t #ary by more than one hour on school!eekend ni(hts

• 8+ercise ' re(ular e+ercise" but o#er*e+ercise can cause headache

• Mealtimes ' 3 meals daily" don@t ski% meals• Hydration ' carry !ater bottle ' school e+cuse to carry and (o to bathroom

• Stress ' stress reduction techni6ues

• $affeine ' moderation or sto%

• nal(esic o#eruse

 '  Eon@t use 5)$ %ain relie#ers more than t!o*three times !eekly '  5%iates can also cause this

 '  )o relie#e headache ' ha#e to break cycle" sto% medication" headache

!orse for 2*3 !eeks" then better:

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#igraine #edications " Preventative

• $y%rohe%tadine ' - && ' insufficient e#idence ' histamine and

serotonin anta(onist !ith $a*channel blockin( %ro%erties S8 ' !ei(ht*

(ain and sedation: $an be 5F for youn(er" non*o#er!ei(ht children:• Beta*blockers ' conflictin( e#idence: S8 ' asthma" EM" orthostatic

hy%otension" de%ression" not (ood for athletes

• mitry%taline .)$@s/ ' de%ressinoaffecti#e disorder often co*morbid

!ith mi(raines: S8 ' G) %rolon(ation ' (et 8F" beha#ior chan(e

• $a*channel blockers ' era%amil ' (ood for hemi%le(ic mi(raine

• 8E@s

 '  )o%ama+ ' S8 ' !ei(ht loss" co(niti#e chan(e" sedation

 '  Ee%akote ' S8 ' !ei(ht (ain" &$5S" terato(enic need $B$;)

monitorin(

 '  Fe%%ra ' consider because lo! S8 %rofile

 '  aba%entin ' S8 ' sedation

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#igraine #edications $ &'ortive

•  -a%ro+en .le#e/ ' 10*20m(k(d di# GH: ;or %atients o#er 30k(: $an (i#e 1*2

tabs at onset" 1 more tab in hours:

• Motrin

• ;ioricet .acetamino%henbutalbitalcaffeine/ or fiorinal ' (ood for rescue but risk ofde%endance" o#eruse ' %robably best not to (i#e outside 8E:

• nti*emetics ' &hener(an" Ie(lan" $om%aine ' can (i#e benadryl to hel% !ith

slee%e+tra%yramidal effects

• )ri%tans ' Sumatri%tan .&5" S$" -/ ' dult oral &5 dose is 2J*100m( at onset"

ma+ 200m(day &5: -o dosa(e recommendations for children in %acket: S8** heart

 ' #asos%asm" M" arrhythmias" H)-" stroke" seiure" rebound headaches

chestKa!neck %ain:

• 8r(ots ' nasal EH8 .Mi(rinal nasal s%ray/ ' 1 s6uirt in each nostril ' S8Lchest

 %ain" nausea" cannot use !ithin 24 hours of tri%tan

• n 8E ' hydration !ith -S" Ma(nesium" Ee%akote" Fetorolac if not medication

o#eruse" com%aine" benadryl" steroid

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eferences

• htt%=eye!iki:aao:or(&a%illedema

• htt%=!!!:kello((:umich:edutheeyesha#eitac6uired%a%illedema:html

• - &ractice %arameter ' mi(raines

• Maria" B: 2009: $urrent mana(ement in child neurolo(y: &eo%le@s medical

 %ublishin( house:

http://eyewiki.aao.org/Papilledemahttp://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.htmlhttp://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.htmlhttp://eyewiki.aao.org/Papilledema