Headaches in Children

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 childrenHeadaches 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 tumortumor

„

„Usually not the caseUsually 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 5Migraine 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

„ „ PrimaryPrimary

--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 Presentation

Clinical Presentation

„

„Acute Acute ––influenza, sinusitis, meningitis, influenza, sinusitis, meningitis,

head injury head injury

„

„SubacuteSubacute––sinusitis, TBMsinusitis, TBM „

„Chronic Progressive Chronic Progressive ––brain brain tumortumor „

„Chronic nonChronic non--progressive progressive ––chronic daily chronic daily

headache headache

Headache Types

Time (days) Time (days) 0 0 3030 6060 Chronic Daily

Headache Types

Headache Types

Mixed/Co

Mixed/Co

-

-

morbid

morbid

Time (days) Time (days) 0 0 3030 6060 Sy mp tom s Sy mp tom s

Evaluation of Headache

Evaluation of Headache

„ Detailed History „ Physical examination „ Neurological examination

„ Formulate a differential diagnosis „ Laboratory tests

„ Treatment „ Follow-up

Post Surgical Headache

Post Surgical Headache

„

„Poor documentation of post surgical Poor documentation of post surgical

headaches in general headaches in general

„

„Headache following epilepsy surgery is Headache following epilepsy surgery is

even less well documented even less well documented

„

„Post 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 site headache overlying the surgical site

Headaches following epilepsy

Headaches following epilepsy

surgery

surgery

„

„Acute Acute --together with other post operative together with other post operative

symptoms which disappear spontaneously symptoms which disappear spontaneously

„

„Chronic headaches are poorly Chronic headaches are poorly

documented documented

Migraine is:

Migraine is:

„

„Almost always familialAlmost always familial „

„Episodic Episodic ––not dailynot daily „

„Variable symptoms:Variable symptoms: Frequency

Frequency AuraAura Severity

Severity Nausea/VomitingNausea/Vomiting Location

Location PhonoPhono/Photophobia/Photophobia

Duration

Migraine May Be:

Migraine May Be:

„

„Associated with Tension Headache.Associated with Tension Headache. „

„Transformed into daily headachesTransformed into daily headaches „

„Related to head trauma/ surgeryRelated to head trauma/ surgery „

„Related to stress/other triggersRelated to stress/other triggers „

„Related to illness/menses/diet Related to illness/menses/diet

Associated with excessive school Associated with excessive school absences absences

History

History

Red Flags

Red Flags

„

„First and worst headache everFirst and worst headache ever „

„Onset of a new type of headacheOnset of a new type of headache „

„Changes in a headache patternChanges in a headache pattern „

„Pain that awakens the patientPain that awakens the patient „

„Pain caused by exertionPain caused by exertion „

„Pain unrelieved by initial treatmentPain unrelieved by initial treatment „

„Pain with neurological symptomsPain with neurological symptoms

Physical Examination

Physical Examination

Red Flags

Red Flags

„

„Patient critically illPatient critically ill „

„Signs of head traumaSigns of head trauma „

„Neck stiffnessNeck stiffness „

„Large headLarge head „

„High fever or the BP is raisedHigh fever or the BP is raised „

Neurological Examination

Neurological Examination

Red Flags

Red Flags

„

„Balance difficultyBalance difficulty „

„Seizures or abnormal movementsSeizures or abnormal movements „

„Altered level of consciousnessAltered level of consciousness „

„Abnormal eye movementsAbnormal eye movements „

„Abnormal Abnormal fundoscopicfundoscopicfindingsfindings „

„Any neurologic abnormalitiesAny neurologic abnormalities

The Good

The Good

A Case Study

A Case Study

„

„ An 11 An 11 y/oy/ogirl 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

contd

contd

„

„ DiagnosisDiagnosis

Migraine without aura Migraine without aura

Migraine:

Migraine:

Goals of Treatment

Goals of Treatment

„Reduction of headache severity,

frequency, duration and disability

„Avoidance of acute/chronic excessive

medication

„Improvement of quality of life „“Normalization”

Migraine: Treatment

Migraine: Treatment

„None „Non pharmacological „Acute – symptomatic „Abortive „Preventive „Combinations

Migraine:

Migraine:

Non

Non

-

-

Pharmacological Approaches

Pharmacological Approaches

„Confident reassurance „Patient/parent education „Diary „Trigger avoidance „ stress/sleep/diet „Environment „ cool/quiet/dark/cold compress „School attendance „Relaxation/biofeedback/counseling

Migraine:

Migraine:

Symptomatic Treatment

Symptomatic Treatment

„Nausea and Vomiting

„Promethazine „Metaclopramide „Ondansetron

Migraine:

Migraine:

Symptomatic Treatment

Symptomatic Treatment

„Sedation „Diphenhydramine „Cyproheptadine „Benzodiazepine

Migraine:

Migraine:

Symptomatic Treatment

Symptomatic Treatment

„Pain „NSAIDS „Ibuprofen „Naproxen „Acetaminophen

Migraine:

Migraine:

Abortive Treatment

Abortive Treatment

„None are FDA approved in children and

adolescents

„Ergotamine- DHE „Triptans

„Imitrex „Zomig

Migraine:

Migraine:

Symptomatic Treatment

Symptomatic Treatment

„MAXIMS: „Treat Early „Maximum Dosages „Avoid combinations „Caffeine „Salicylates „Barbiturates

The Bad

The Bad

A Case Study

A Case Study

„

„ A 15 A 15 y/oy/ogirl has had girl has had frontotemporalfrontotemporalH/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 NSAIDsNSAIDsand 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

contd

contd

„

„DiagnosisDiagnosis

Severe migraine with aura Severe migraine with aura

Treatment Options

Treatment Options

„

„SymptomaticSymptomatic „

„Abortive medicationAbortive medication „

„Preventive medicationPreventive medication „

„OtherOther

Migraine:

Migraine:

Consider Preventive Treatment

Consider Preventive Treatment

„

„Significant interference with ADL / QOLSignificant interference with ADL / QOL „ „HeadachesHeadaches „ „> 2 / week> 2 / week „ „> 24 hours> 24 hours „

„Unresponsive to symptomatic/abortive Unresponsive to symptomatic/abortive

medications

medications

„

„With OTC overuseWith OTC overuse

Migraine:

Migraine:

Preventive Treatment

Preventive Treatment

„

„None are FDA approved in children and None are FDA approved in children and

adolescents adolescents

„

„AntiAnti--histamineshistamines--periactinperiactin „

„TricyclicTricyclicantidepressants antidepressants --elavilelavil „

The Ugly

The Ugly

A Case Study

A Case Study

„

„ A 14 A 14 y/oy/ogirl 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 2

frequency 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

phono

phono/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. „

„ NeurologicNeurologicexam is normal.exam is normal.

“Rack Our Brains”

Differential Diagnoses

Differential Diagnoses

„

„Illness plus migraineIllness plus migraine „

„MeningitisMeningitis „

„Status Status migrainosusmigrainosus „

„OtherOther

Testing

Testing

„

„ Blood testsBlood tests

„

„ CT/MRICT/MRI

„

„ Spinal tapSpinal tap

Case

Case

contd

contd

„

„DiagnosisDiagnosis

Status

Status MigrainosusMigrainosus

Treatment Options

Treatment Options

Admit to infusion center

Admit to infusion center

„

„SedationSedation

„

„AntiemeticAntiemetic

„

„Anticonvulsants / DHEAnticonvulsants / DHE

„

Treatment Options

Treatment Options

„

„Confident reassuranceConfident reassurance „

„Patient / parent educationPatient / parent education „

„D/C OTC medicationsD/C OTC medications „

„Return to school is a mustReturn to school is a must „ „CounselingCounseling „ „MedicationMedication „ „FollowFollow--upup