Headache in Children

Pain-sensitive structures in the head

Intracranial Structures• Venous sinuses and afferent veins

• Arteries of the dura materand pia-arachnoid

• Arteries of the base of the brain and their major branches

• Parts of the dura matter near the large vessels

Pain-sensitive structures in the head

Extracranial Structures• Skin• Subcutaneous tissue• Muscles• Periosteum of the skull• Mucosa• Extracranial arteries• Delicate structures of

the eye, ear, nasal cavities and sinuses

Pain-sensitive structures in the head

Nerves• Trigeminal• Facial• Glossopharyngeal • Vagus• Upper three cervical roots

Pathophysiology of headache:Pain insensitive structures

SkullPia-arachnoid and dura over the

convexity of the brainBrain parenchymaEpendymaChoroid plexuses

Pain Mechanisms

TractionOn the Circle of Willis and dural structures

InflammationOf intra- and extracranial structures Of the meninges, and blood vessels

Vascular distention and spasmOf intra- and extracranial vessels

Pain Mechanisms

Muscle contractionOf neck and scalp muscles

Pressure- changes in ICP

- Within nasal or paranasal cavities, orbits, ears and teeth, and on nerve-containing fibers

Temporal profile of headache

Acute Acute RecurrentChronicprogressive

Chronicnonprogressive

Time (days)0 30 60

Migraine

most important and frequent type of headache in the pediatric population

PrevalenceGirls - adolescents Boys - younger than 10 yr

50 % spontaneous prolonged remission after the 10th birthday

Adults, 5–10% of men and 15–20% of women have migraine headaches

Migraine without aura

the most prevalent type of migraine in children headache is throbbing or pounding and tends

to be unilateral at onset or throughout its duration but may also be located in the bifrontal or temporal regions

It may not be hemicranial in children and is less intense compared with the migraine in adults

Migraine without aura

headache usually persists for 1–3 hr although the pain may last for as long as 72 hr

pain may inhibit daily activity, because physical activity aggravates the pain

characteristic feature intense nausea and vomiting

Migraine without aura

Additional symptoms extreme paleness, photophobia, light-

headedness, phonophobia, osmophobia (aversion to odors), and paresthesias of the hands and feet

positive family history on the maternal side in ≈90% of children with migraine without aura

Migraine without aura

Additional features near synchrony with perimenstrual or periovulation

timing gradual appearance after sustained exercise relief with sleep stereotypical prodromes (hypersomnia, food

craving, irritability, moodiness) precipitation by food or odors onset after a letdown or high period of stress

Diagnostic Criteria Migraine without aura

 A    At least five attacks  B    Headache attack lasts 1–72 hr (untreated or unsuccessfully

treated) C    Headache has at least two of the following characteristics:  

 Unilateral location, may be bilateral   Pulsating quality  Moderate or severe intensity  Aggravation by or avoidance of routine physical activity

(i.e., walking or climbing stairs)D    During headache at least one of the following:  

 Nausea, vomiting, or both  Photophobia and Phonophobia 

 E    Not attributed to another disorder

Migraine with aura

Aura precedes the headache Visual aura are uncommon in children but

when they occur they may be in the form of Binocular visual impairment with scotoma (77%) Distortion or hallucinations (16%) Monocular visual impairment or scotoma (7%)

[hachinshi et al., 1973]

Migraine with aura

Vertigo and light headedness Sensory symptoms

Perioral paresthesias Numbness of the hands and feet

Distortion of body image (alice in wonderland)

DIAGNOSTIC CRITERIAWITH AURA (CLASSIC MIGRAINE)

A    At least two attacks  

B  Migraine aura fulfills criteria for typical aura, hemiplegic aura,

or basilar-type aura  

C    Not attributed to another disorder

DIAGNOSTIC CRITERIAWITH AURA (CLASSIC MIGRAINE)

TYPICAL AURA  1    Fully reversible visual, sensory, or speech

symptoms (or any combination) but no motor weakness 

 2    Homonymous or bilateral visual symptoms including positive features (e.g., flickering lights, spots, lines) or negative features (e.g., loss of vision), or unilateral sensory symptoms including positive features (e.g., visual loss, pins and needles) or negative features (i.e., numbness), or any combination 

 

DIAGNOSTIC CRITERIAWITH AURA (CLASSIC MIGRAINE)

 3    At least one of: 

 a) At least one symptom develops gradually over a minimum of 5 min, or different symptoms occur in succession, or both

  b) Each symptom lasts for at least 5 min and for no longer than 60 min  

4    Headache that meets criteria for migraine without aura begins during the aura or follows aura within 60 min

Hemiplegic Migraine

A migraine auraSudden onset of unilateral sensory or

motor signs during the migraine episodeCharacterized as numbness of the face ,

arm, leg, unilateral weakness and aphasiaMay be transient or may persist for days

Hemiplegic Migraine

Good prognosis(+) family history of hemiplegic migraine

Basilar-type migraine

Brainstem signs predominate because of the vasoconstrictor of the basilar and posterior cerebral arteries

Vertigo, tinnitus, diplopia,blurred vision, scotoma, ataxia and occipital headache

Pupils may be dilated, ptosisAlteration in consciousness followed by

seizures may occur

Basilar-type migraine

There is complete resolution of the neurologic signs and symptoms

Minor head injury can precipitate the headache

M = FGirls < 4 years old of higher risk

Childhood Periodic Syndromes—Migraine Precursor

Cyclic vomiting

Periodic Syndromes—Migraine PrecursorCyclic vomiting

Diagnostic Criteria: A. At least five attacks fulfilling criteria B and C B. Episodic attacks, stereotypical in the individual

patient of intense nausea and vomiting lasting 1-5 days

C. Vomiting during attacks occurs at least 5 times/ hour for at least 1 hour

D. Symptom-free between attacks E. Not attributed to another disorder. History and

Physical Examination do not reveal signs of gastrointestinal disease.

Childhood Periodic Syndromes—Migraine PrecursorCyclic vomiting

Treatment rectally administered or injected

antiemetics such as dimenhydrinate or ondansetron

careful attention to fluid replacement if the vomiting is excessive

Precursors of migraineAbdominal migraine

Description:An idiopathic recurrent disorder seem

mainly in children & characterized by episodic midline abdominal pain manifesting in attacks lasting 1-72 hours with normality between episodes. The pain is of moderate-to-severe intensity & associated with vasomotor symptoms, nausea and vomiting.

Precursors of migraineAbdominal migraine

Diagnostic Criteria:

A. At least 5 attacks fulfilling criteria B through D

B. Attacks of abdominal pain lasting 1-72 hours

C. Abdominal pain has all of the ff. characteristics

A. Midline location, periumbilical or poorly localized

B. Dull or “just sore” quality

C. Moderate or severe intensity

D. During abdominal pain, at least two of the ff:

A. Anorexia

B. Nausea

C. Vomiting

D. Pallor

Management of Pediatric MigraineGoals of Treatment

1. Reduction of headache frequency, severity, duration, and disability

2. Reduction of reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapies

3. Improvement in quality of life 4. Avoidance of acute headache medication escalation 5. Education and enabling of patients to manage their

disease to enhance personal control of their migraine  

6. Reduction of headache-related distress and psychological symptoms

Treatment of Pediatric MigraineAcute attack

Analgesic1. acetaminophen (15 mg/kg)

2. ibuprofen (7.5–10 mg/kg) Antiemetic

1. dimenhydrinate by rectal suppository 5 mg/kg/24 hr in four divided doses

2. Parenteral metoclopramide

Treatment of Pediatric MigraineAcute attack

Triptans (e.g., Sumatriptan) are specific and selective 5-hydroxytryptamine

receptor agonists that are effective abortive drugs Sumatriptan may be administered

subcutaneously, nasally, or orally suggested dose is 5 mg in children <25 kg, 10 mg (two sprays) in those weighing 25–50 kg,

and 20 mg sumatriptan in children ≥50 kg

TreatmentAcute attack

Triptans (e.g., Sumatriptan) dose may be repeated 2 or more hours

after the initial dose, limited to two doses per 24 hr

adverse effects are usually minor and transient, and include hot flushes, nausea and vomiting, fatigue, and drowsiness

Children may develop severe intractable migraine attacks or status migrainosus (persistent headache lasting longer than 3 days) that are unresponsive to conventional drug regimens Intravenous prochlorperazine, 0.15 mg/kg

(max 10 mg)

continuous daily medication (prophylactic therapy)

severity and frequency of the headaches on the impact of the migraine on the

child's daily activities, including school attendance and performance as well as participation in recreation

if a child experiences more than two to four severe episodes monthly or is unable to attend school regularly

continuous daily medication (prophylactic therapy)

Ppropranolol 10–20 mg tid (beginning with 10 mg/24 hr

and gradually increasing the drug to the maximum dose or until the desired therapeutic effect is achieved) in children 7–8 yr and older.

A common mistake is to discontinue the drug prematurely, because it often takes several weeks to a month until the drug is effective.

continuous daily medication (prophylactic therapy)

Flunarizine initial dose is 5 mg at bedtime and

increased if necessary to 10 mg most frequent side effect is drowsiness

Behavioral Management

effective method for the treatment of migraine in some children and adolescents

Biofeedback can be mastered by most children older than 8 yr and has been effective in many clinical trials

Indications for Neuroimaging in a Child with Headaches

Abnormal neurologic signRecent school failure, behavioral

change, fall-off in linear growth rateHeadache awakens child during sleep;

early morning headache, with increase in frequency and severity  

Periodic headaches and seizures coincide, especially if seizure has a focal onset  

Indications for Neuroimaging in a Child with Headaches

Migraine and seizure occur in the same episode, and vascular symptoms precede the seizure (20–50% risk of tumor or arteriovenous malformation)

Cluster headaches in child; any child <5–6 yr whose principal complaint is a headache  

Focal neurologic symptoms or signs developing during a headache (i.e., complicated migraine) 

Indications for Neuroimaging in a Child with Headaches

Focal neurologic symptoms or signs (except classic visual symptoms of migraine) develop during the aura, with fixed laterality; focal signs of the aura persisting or recurring in the headache phase 

 Visual graying-out occurring at the peak of a headache instead of the aura  

Brief cough headache in a child or adolescent