childhood headache rachel howells. learning outcomes by the end of this session, you should be able...
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Childhood HeadacheRachel Howells
Learning Outcomes
By the end of this session, you should be able to
Differentiate primary from secondary headache
Recognise and manage common primary headaches
Epidemiology
Preschool1/3 will have had a headacheMigraine headache 0-7% of population
Schoolchildren70% have ≥ 1 headache a yearPeak at 90% at age 12-13Prevalence of recurrent headache 20-30%
Case 1
Case 1
15 year old girl
Frontal headache, down neck and shoulders
2 monthsStart as soon as she rises from bed, and
relieved by lying downMissing school for 6 weeks
Primary or Secondary?
Case 1
Further historySpinal surgery 3 months ago Epidural anaesthesia
Examination Normal
Low pressure headache
Possible dural tap
ManagementEncourage mobilising Many spontaneously resolve within 3-4
monthsShort-term: CaffeineLong-term: Epidural blood patch
Primary vs Secondary Headache
Primary vs Secondary Headache
10% of headaches seen in a specialist neurology / headache clinic are secondary in origin
Population prevalence of organic disease is likely to be lower
Secondary Headache Types
Altered Intracranial PressureRaised ICPLow Pressure Headaches
VascularSubarachnoid Headache (eg AVM)DissectionVasculitisDrugs
Drug effectAnalgesia induced headache
Central (thalamic) painTrigeminal neuralgiaCluster headaches
LocalDental AbscessSinusitisPost head injury
How to identify a secondary headache
How to identify a secondary headache
Brain Imaging
Examination
History
Indications that a headache is secondary to altered intracranial pressure
Indications
1. Timing of headache
2. Postural manoeuvres
3. Associated symptoms
Timing of Headache
Morning but from sleep, before rising
Raised Intracranial Pressure
Morning but after getting up
Low Pressure Headache
Postural Manoeuvres
Getting up relieves headache
Coughing and straining exacerbates it
Raised Intracranial Pressure
Lying down relieves headache
Low Pressure Headache or
Sinusitis
Associated Symptoms
Frontal headache
Associations Morning vomitingOther neurology
Confusion
Raised Intracranial Pressure
Frontal headache
AssociationsPain / parasthesiae across shoulders*
Blocked nose, facial pain¤
Low Pressure Headache* or
Sinusitis¤
Case 2
Case 2
16 year old girl seen in OPD
Frontal headache There when she wakes, gets better when
she gets upNo nausea or other neurological
symptoms
4 months, not getting any worse
Primary or Secondary?Is this raised or low intracranial pressure?
Case 2 continued
Past History – nil
Examination Enlarged blind spots on confrontationNo other alteration of visual fieldsPapilloedema
No ataxia, long tract signs
What diagnoses need to be considered?
Causes of Raised Intracranial Pressure
HydrocephalusTumour obstructing CSF pathways Obstruction to CSF re-absorption (post haemorrhage or meningitis)Congenital (eg aqueduct stenosis)
Cerebral oedemaInflammation (ADEM, stroke)Infection (meningitis etc)CO2 retention (obstructive sleep apnoea)Metabolic (DKA, other)
Idiopathic (Benign)Intracranial Hypertension
Idiopathic Intracranial Hypertension
Aetiology unknownAdolescent girlsObesity, drugs, steroid withdrawalVisual loss (10%) may be permanent and
is only indication for treatment
Raised intracranial pressure in the absence of space occupying lesion
or obstruction to CSF flow
Indications
1. Timing of headache
2. Postural manoeuvres
3. Associated symptoms
Case 3
Case 3
14 year old girlHeadache since the evening beforeSingle and worst headache everSudden onset
Vomited once at start
No history of head injury / prodrome
Case 3
ExaminationAfebrileNo meningismGCS 15
Unilateral facial weakness with frontal sparing
Ipsilateral arm weakness with hyporeflexia
What diagnoses should you entertain?
CT brain
Case 3
CT shows haemorrhage around area of left basal ganglia
Patient admits to using some cocaine at a party with her 18 year-old sister
More information to help you identify secondary
headache
History
Timecourse
Single or first severe headache
Recurrent severe headachesOne a month
2 years without progression
Headaches all day on most days
18 months
Headaches every few monthsthen weeksthen days
Now every day
Severe headaches all day for 12 days2 months ago
None since
Bleed?
Bleed?
Tumour?
TTH?
Migraine?
Timecourse
Single or first severe headache
Recurrent severe headachesOne a month
2 years without progression
Headaches all day on most days
18 months
Headaches every few monthsthen weeksthen days
Now every day
Severe headaches all day for 12 days2 months ago
None since
Pointers in History: Summary
1. Timing of Headache
2. Postural manoeuvres
3. Symptoms associated with headache
4. Timecourse
Examination
Purpose of Examination
To support your clinical impression made on history
To rule out other differentialsTo adhere to many families expectations
to be taken seriouslyto be able to support your view that nothing serious
is going on
Essential elements of Examination
VisionAcuityFields including blind spotExtraocular movementsLong tract signs
TonePower Reflexes
Cerebellar signsFinger-nose test (eyes shut)TremorDysarthriaGait
Blood pressure
Bruit
Conscious level
Fundi
Case 4
Case 4
8 year old boy with 10 month history of Bi-temporal headacheThrobbingWorse with movement / exerciseMother says looks pale and unwell
Usually start in morningLast all day
Case 4
No family history
Examination is normal
Primary or Secondary?
What is the most likely diagnosis?
Migraine without aura
What causes migraine?
Migraine headache Nerve efferents – trigeminal,
vagal Meninges have pain fibres with
inputs from trigeminal complex Vasodilation of meningeal
vessels
Michael Creighton
Why do some people get migraine headaches?
Genetic
Abnormal inhibitory inputs to trigeminal nerve complex
Clinical Implications
Abnormal inhibition to nociceptive parts of brain
Abnormal response to changes in environment eg sleep, diet, smells
Pain is exacerbated by noise and light
Headache relieved by sleep in a dark room
Migraine symptoms Pain involves the face
(trigeminal) Throbbing pain (meningeal) Pallor and nausea (vagal)
Delia Malchert
Migraine
ClassificationMigraine without aura (commonest)Migraine with aura
Basilar migraineOphthalmoplegic migraineAlternating hemiplegia
Migraine
The diagnosis is a clinical one
Families can be reassured byFamily historyLongevity of symptomsNormal examinationAddressing their underlying concerns
Management
1. Explanation
This is not a tumour Worst in second decade of life Most patients will get fewer headaches
as they get older
Management
2. Treatment of attacks
Analgesia as soon as an attack starts Ibuprofen works best (one RCT)May be supplemented by anti-emetic
Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)
Management
3. Prevention – control of environment
‘Sleep hygiene’ – regular sleep ‘Diet hygiene’ – avoid long breaks ± snack
before bed, avoid caffeine, low amine diet ‘Exercise hygiene’ – regular exercise,
maintain hydrationAvoid stress – relaxation training, CBT
Management
4. Prevention – pharmacological
No magic bullet, trial basis onlyPizotifenPropanolol
Feverfew
Case 5
Case 5
10 year-old girl with 18 month history ofBilateral headache, mainly vertexConstantComes on during day Not worsened by walkingNo aura or pallor / nausea
5/7 days a week, most weeks of the year
Case 5
No family historyExamination normal
Local grammar schoolPredicted for A grades in 10 GSCEs No external sources of anxiety – stable
home, not being bulliedTrying to keep going to school
Case 5
Alternating ibuprofen 400mg and co-codamol for headaches
‘Nothing really works’
Primary or secondary?
What is the most likely diagnosis?
Chronic Tension-Type Headache
How is the diagnosis made?
CTTH
No features suggestive of organic diseaseTime of dayPostural manoeuvresAssociated symptoms Time course
Not classifiable as migraineExamination normal
Management
Explanation
Although not an organic disease, effects on life can be significant (school etc)
Treat attacks Simple analgesia Avoid multiple drugs Feverfew / Levomenthol / TigerBalm
Management
Prevention of attacks
Sleep, diet, exercise hygieneAddress anxiety (relaxation training, CBT)Maintain contact with school, try and
attend but manage workload
What did you learn?
You should now be able to
Differentiate primary from secondary headache
Recognise and manage common primary headaches
Migraine with / without auraTension-type headache
Any questions?
Thank you for listening
Rachel Howells
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