Pediatric Neurology Quick Talks

HeadacheMichael Babcock

Summer 2013

Scenario

• 7 yo boy

• Headaches for 4 months

• Headaches last 90 minutes

• Grabs the front of his head when it hurts

• Has about 1 headache a week, vomits with some of the headaches

• Continues to do well in school, no vision complaints

Causes of headache

• Primary

– Migraine

– Tension-type

– Cluster

– Paroxysmal hemicrania

– SUNCT

– Trigeminal neuralgia (not common in kids)

– Chronic daily headache

• Secondary

– Medication overuse (rebound)

– head/neck trauma

– Vascular disorder – SAH, AVM, vasculitis, CSVT

– High ICP / Low ICP

– Tumor

– Infection

• CNS

• Other infections

History

• Headache – quality, severity, location, laterality, onset, time course – episodic and similar or progressive/changing

• Associated symptoms – systemic symptoms, fever, personality changes, seizures

• Preceding symptoms – aura, gradual/rapid onset

• Exacerbating features – migraines worse with activity; worse with laying or nocturnal or with cough/straining – signs of elevated ICP; worse with standing – signs of low ICP.

• Medical history – NF1, Sturge-weber, connective tissue disorder, Sickle cell, immunocompromised.

Exam

• Vitals – fever, ICP signs

• Good neurologic exam

– ? Altered mental status

– Abnormal eye movements

– Visual field testing

– Fundoscopic exam

– Focal weakness

– UMN signs

– Abnormal gait

Papilledema (normal to severe)

Work-up

• Imaging

– Trauma

– Associated seizures

– AMS

– Abnormal neurologic exam

– Historical features – thunderclap headache, persistently lateralized, progressive course, shunt, change in pattern/type, occipital headache

– Signs of elevated ICP

– Considerations:

• no family history of migraine

• < 1 month of headache

• Young age of onset

– Prior to LP

• CSF analysis

– Pseudotumor (IIH)

• Accurate recording of pressure, in lateral decub position must extend LE's.

– Meningitis

• Meningismus

• Fever

• New seizures

• AMS

• immunocompromised

– SAH

• Thunderclap headache

Migraine

• Affects 7% of all children

• Causes $1-17 billion in lost productivity

• Accounts for 10 million physician visits/year in U.S.

Migraine Classification

• Pediatric migraine with aura– At least 2 attacks fulfilling B.

– At least 3 of the following

• One or more fully reversible aura symptom indicating focal cortical and/or brainstem dysfunction

• at least 1 aura developing gradually over > 4 min or > 2 aura symptoms occurring in succession

• No auras lasting > 60 minutes

• Headache no more than 60 minutes after aura

Migraine treatment – Life-style modification

• Sleep – don't vary by more than one hour on school/weekend nights

• Exercise – regular exercise, but over-exercise can cause headache

• Mealtimes – 3 meals daily, don't skip meals

• Hydration – carry water bottle – school excuse to carry and go to bathroom

• Stress – stress reduction techniques

• Caffeine – moderation or stop

• Analgesic overuse

– Don't use OTC pain relievers more than two-three times weekly

– Opiates can also cause this

– To relieve headache – have to break cycle, stop medication, headache worse for 2-3 weeks, then better.

Migraine Medications - Preventative

• Cyproheptadine – AAN PP – insufficient evidence – histamine and serotonin antagonist with Ca-channel blocking properties; SE – weight-gain and sedation. Can be OK for younger, non-overweight children.

• Beta-blockers – conflicting evidence. SE – asthma, DM, orthostatic hypotension, depression, not good for athletes

• Amitryptaline (TCA's) – depressino/affective disorder often co-morbid with migraines. SE – QT prolongation – get EKG, behavior change

• Ca-channel blockers – Verapamil – good for hemiplegic migraine

• AED's

– Topamax – SE – weight loss, cognitive change, sedation

– Depakote – SE – weight gain, PCOS, teratogenic; need CBC/LFT monitoring

– Keppra – consider because low SE profile

– Gabapentin – SE – sedation

Migraine Medications – Abortive

• Naproxen (Aleve) – 10-20mg/kg/d div Q8H. For patients over 30kg. Can give 1-2 tabs at onset, 1 more tab in 8 hours.

• Motrin

• Fioricet (acetaminophen/butalbital/caffeine) or fiorinal – good for rescue but risk of dependance, overuse – probably best not to give outside ED.

• Anti-emetics – Phenergan, Reglan, Compazine – can give benadryl to help with sleep/extrapyramidal effects

• Triptans – Sumatriptan (PO, SC, IN) – Adult oral PO dose is 25-100mg at onset, max 200mg/day PO. No dosage recommendations for children in packet. SE-- heart – vasospasm, MI, arrhythmias, HTN, stroke, seizure, rebound headaches; chest/jaw/neck pain.

• Ergots – nasal DHE (Migrinal nasal spray) – 1 squirt in each nostril – SE—chest pain, nausea, cannot use within 24 hours of triptan

• In ED – hydration with NS, Magnesium, Depakote, Ketorolac if not medication overuse, compazine, benadryl, steroid

References

• http://eyewiki.aao.org/Papilledema

• http://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.html

• AAN Practice parameter – migraines

• Maria, B. 2009. Current management in child neurology. People's medical publishing house.