Transcript HEADACHE - SBH Peds Res

CONTINUITY LECTURE
SAMATHA MADHAVARAPU
PGY -1
EPIDEMIOLOGY
 Significant health problem for children and
adolescents.
 Up to 75% of children report having a
significant headache by the time they are 15
years of age
 10.6% of children between 5 and 15 years had
migraine
Meta-analysis of pediatric
headache
 3-7 Years : (1.2% to 3.2% )Slightly male predominance
 7-11 Yrs : 4–11% Equal male and female predominance.
 11- 15 years of age: 18–23% Female predominance
 15 – 19 Yrs : 28% had migraine, Females, migraine without
aura common
 81% of adolescents with migraine had a positive family
history.
 TTHs have been less well studied than migraine
 Migraine has a genetic component
 Degree of inheritance as high as 90% in first- or
second-degree relatives
 TTHs are generally considered mild recurrent
headaches (previously called muscle contraction
headache, idiopathic headache, and tension headache
 Impact of headaches
 1989 National Health Interview Survey found that
within a 2-week period, 975,000 children had a
migraine, resulting in 164,454 missed school days.
International Classification of
Headache Disorders (ICHD-II).
Primary Headaches
Secondary Headaches
 Directly attributed to a
 Attributed to a specific non-
neurologic basis
neurologic cause.
 Migraine
 Infectious
 Tension-type headaches
 Vascular
(TTHs)
 Cluster headaches
 Other primary neuralgias
 Traumatic
 Toxic
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Including medications and
overuse of medications
 Mass lesion
Evaluation
 After the detailed history and medical examination, it
should be possible to determine whether the patient
has a primary or secondary headache
 The first step in evaluating a child with headache is to
rule out secondary causes
Detailed Headache History
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Length of time the child has had headaches
Severity
Quality :Throbbing, pulsating, tightness, pressure,
squeezing, sharp, stabbing, dull
Location :frontal, temporal, occipital, unilateral, bilateral
Duration : number of minutes, hours, or days
Frequency : number per month, time interval between
headaches
The effect on the child’s quality of life and disability
Any aura before headaches
Presence of Nausea/ vomitting
History contd
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Time of onset: specific time of day, night-time waking, relationship
to particular activity/ menses
Precipitating factors: foods, odors/ perfumes, stressors
Ameliorating factors: sleep, exercise, quiet, dark room
Associated factors: photophobia, phonophobia
Lifestyle factors: sleep pattern, exercise; diet: caffeine intake,
chocolate, aged cheeses, processed meats, monosodium glutamate,
nuts, and pickles
Personality change: crying, rocking, holding head, decreased
activity/eating in younger children; withdrawal in older children
What does the child/adolescent think is causing the headache?
Prior treatment: response to past treatment, frequency of use of
over-the-counter or prescription medications, use of herbs, vitamins,
supplements, or alternative therapies
Activities; changes in school attendance or performance; smoking,
alcohol, or other substance abuse Detailed review of systems
History contd
 Medical History : trauma, infection, allergies,
ventriculo-peritoneal (VP) shunt placement , epilepsy,
atopic disorders, diabetes mellitus, depression or other
psychiatric disorders
 Family History : headaches in first- and seconddegree relatives
 Social History : Changes or stressors in the home,
school, or outside the home or school should be
obtained
Physical Exam
 Conducting a physical examination is important, with
an emphasis on the neurologic examination.
 Include a thorough search for potential sources of
secondary headache.
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Increased intracranial pressure
Sinusitis
Dental disease
Abnormalities of the cervical spine
Temporomandibular joint disorders
Secondary headache causes
 Head or neck trauma
 Cranial or cervical vascular
disorder
 Nonvascular intracranial
disorder
 High-pressure headaches
 Low-pressure headaches
 Substance use/abuse or
withdrawal
 Includes medication overuse
headaches
 Infection
 Brain abscess
 Meningitis
 Encephalitis
 Disorders of homeostasis or
facial pain extending from
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Cranium
Neck
Eyes
Ears
Nose
Sinuses
Teeth
Mouth
 Psychiatric disorders
MIGRAINE
Migraine without aura, previously called common migraine
or hemicrania simplex
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Recurrent headache disorder
Attacks last 4–72 hours.
Typical characteristics
 More often bilateral, orbital, or frontotemporal,
 Pulsating quality
 Moderate or severe intensity
 Aggravation by routine physical activity
 Association with nausea, photophobia, phonophobia ,
unexplained paroxysmal abdominal pain
 GI symptoms
 60-85% of migrainous children
Phases of Migraine attack
 Premonitory phase or prodrome : may precede the
headache phase by up to 24 hours
 irritability, elation or sadness, talkativeness or social
withdrawal, an increase or decrease in appetite, food
craving or anorexia, water retention, and/or sleep
disturbances
 Aura: focal cerebral dysfunction that immediately
precedes or coincides with the headache onset
 Only 10-20% of children with migraine experience an
aura
Phases of Migraine
 Aura: precedes the headache by less than 30 minutes
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and lasts for 5-20 minutes
Motor auras last longer
Children are often unaware or unable to describe
pictorial cards
The visual aura is the most common form in children,
blurred vision, fortification spectra (zigzag lines),
scotomata (field defects), scintillations, black dots,
kaleidoscopic patterns of various colors, micropsia,
macropsia (distortion of size), and metamorphopsia
("Alice in Wonderland" syndrome). moving or
changing shapes
 other auras include attention loss, confusion, amnesia,
agitation, aphasia, ataxia, dizziness, vertigo,
paraesthesia, or hemiparesis.
 Actual headache phase : usually shorter in children,
30 min- 48hrs. less severe
 Postdrome : patient may feel either elated and
energized or exhausted and lethargic
MIGRAINE
 Migraine with aura (classic migraine)
 Aura consists of visual, sensory, or speech symptoms.
 Gradual development
 Duration ≤1 hour
 Complete reversibility
 In addition to the aura, the headache will have symptoms of
migraine without aura.
 Chronic migraine
 Frequent headaches (≥15 times per month for the previous 3
months)
 Presence of migraine features
 Cannot be attributed to a secondary cause
 Status migrainosus: severe form of migraine .
Headache continuous for over 72 hours. Hydration
imp for those with vomiting. Iv dihydroergotamine/
valprote is treatment.
 Familial hemiplegic migraine : autosomal dominant
form of migraine with aura
 prolonged hemiplegia accompanied by numbness,
aphasia, and confusion. precede, accompany, or follow
the headache. headache is usually contralateral to the
hemiparesis
Basilar migraine
 Subtype of migraine with aura.
 Occipital headache.
 Disturbances in function originating from the brain stem,
occipital cortex, and cerebellum
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Ataxia
Bilateral paresthesias
Deafness
Decreased level of consciousness
Diplopia
Dizziness
Drop attacks
Dysarthria
Fluctuating low-tone hearing loss
Tinnitus
Unilateral or bilateral vision loss
Vertigo
Weakness
Cyclic vomiting syndrome
 Migraine-associated cyclic vomiting syndrome
(periodic syndrome)
 Recurrent periods of intense vomiting separated by
symptom-free intervals
 Rapid onset at night or in the early morning. Nausea,
anorexia, abd pain, pallor, headache,
photo/phonophobia.
 Begins when the patient is a toddler and resolves in
adolescence. family history of migraine
 Respond to antimigraine drugs
TTH s
 Generally considered mild recurrent headaches
 Many features are the opposite of those of migraine.
 TTHs can be subdivided based on frequency.
Infrequent, episodic
Frequent, episodic
Chronic
 Diffuse in location
 Having a pressing quality
 No secondary causes are identified
 Cluster headache
 histamine headache
 severe and unilateral, sudden onset
 typically are located at the temple and periorbital region
 ipsilateral lacrimation, nasal congestion, conjunctival
injection, miosis, ptosis, and lid edema
 few moments to 2 hours
 grouping of headaches, usually over a period of several
weeks.
 at least 5 attacks occurring from 1 every other day to 8
per day and no other cause for the headache.
 Distribution - First and second divisions of the
trigeminal nerve
Danger Signs and Symptoms of Life Threatening
Conditions that Can Present with a Headache
 History:
No family history in presence of other signs & symptoms
Lack of response to medical therapy
Early morning pain, with/without headache
Night time awakening with pain
Persistant vomiting
Increased pain with coughing/bowel movt/voiding
Chronic progressive pain
Worst headache that has ever had
Personality change (depression &migraine indicate
temporal lobe tumor)
Physical exam
 Age <3yrs
 Known risk for intracranial pathology
V-P shunt malfunction
Neurofibromatosis
Tuberous sclerosis
 Abnormal Neurologic exam
Seizures, lethargy, ataxia
hemiparesis, abn reflexes, diplopia, papilledema,
meningeal signs
Imaging
 If abnormalities on the neurologic examination cannot be
explained by medical history, then neuroimaging may be
required to identify a medically or surgically treatable
cause of the headaches.
 The decision to perform neuroimaging on a child with
headache is made based on the history and physical.
 Neuroimaging in children with recurrent headache but a
normal examination routinely is not recommended
 Neuroimaging should be considered for children with
headaches with abnormal neurologic examinations and/or
seizure, recently occurring severe headaches, change in
headaches, or associated neurologic dysfunction
Treatment Approach
 In patients with secondary headaches, the treatment goal is
to address the underlying cause.
 Headaches should resolve once the underlying cause is
addressed.
 Treatment of primary headache disorders in children must
be 3-fold.
 Acute therapy
 Preventive therapy
 Biobehavioral therapy
 Clear goals of treatment must be discussed with the patient
and parents
Short-term therapy
 To ameliorate episodic headache and return to N
baseline.
 NSAIDS: Ibuprofen, Naproxen
Mainstay for the acute treatment of childhood
headaches and migraines
Good tolerability, Effective in clinical trials.
Proper use of ibuprofen needs:
Initiation of rapid treatment
Proper dosing
Avoidance of overuse; limited to ≤3 times per week
 When NSAIDs are ineffective or not completely
effective, switch to migraine-specific therapy
Triptans
 5-HT1B-1D agonist migraine-specific medications
 Relieve not only pain but also nausea, vomiting, photophobia, and
phonophobia.
 Sumatriptan, zolmitriptan, rizatriptan
 Use of these drugs for migraine relief in children has not been formally
approved.
 Sumatriptan nasal spray (especially in the teenage population) has been among
the most extensively studied; sumatriptan subcutaneous in small doses for
severe migraine can be considered. Use in persons <8 y not recommended
 Two treatment methods
 Rescue therapy or Stepwise treatment within an attack.
 Starts with NSAID at the onset & if it fails, use triptan
 Step wise Rx:
Mild /moderate pain: NSAID
Severe headache: triptan
Dihydroergotamine (DHE)
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Long history of usefulness in migraines
Frequently used in the emergency management of
childhood headaches
Breaks status migrainosus or prolonged migraines in
children
Has significant adverse effects, including vomiting
The effect may be enhanced if patients are
premedicated with dopamine antagonists
 Dopamine antagonists (prochlorperazine,
metoclopramide)
 Used for nausea and vomiting effects of migraine
headaches
 Combines an antiemetic effect but also a direct
antimigraine effect because of antidopamine action
 Dopamine antagonists should be given intravenously.
 Their utility is limited by extrapyramidal side effects.
 It is suggested that prochlorperazine can be used to
break an acute episode of status migrainosus.
 Best given with rehydrating fluids in the emergency
room setting
Prophylactic treatment
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Second component
Started when headache becomes frequent / disabling
Goal: minimize the effect & number of headaches
Having >2–3 headaches per month typically warrants
treatment
 For all prophylactic medications, titrate doses slowly to
an effective level
 This may be a lengthy process (weeks, months)
 Migraine preventives: flunarizine, gabapentin ,
riboflavin , metoprolol.
Antiepileptics
 Only divalproate sodium and topiramate are currently
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approved for the prevention of migraines in adults; they are
not approved for children
Divalproate: Has not been formally approved for use in
migraine in persons <16 y . safe use younger than that age
has been reported
Topiramate : initial studies point to good efficacy and
tolerability
Antidepressants :
Most widely used tricyclic antidepressant for headache
prevention is amitriptyline.
First recognized in the 1970s as an effective migraine
therapy
 Amitriptyline was found to be effective in 50–60% of
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children in a cross-over study comparing amitriptyline with
propranolol and cyproheptadine
There are no placebo-controlled studies with amitriptyline.
Titrate slowly over 8-10 weeks to minimize somnolence
Cannot be formally recommended for individuals <12 y
Nortriptyline : Potential for increased arrhythmias
Regular EKG is needed.
SSRI s not yet studied, , not as effective as more global
decrease in neurotransmitter reuptake inhibition is needed
to treat childhood headache disorders
Cyproheptadine
 An antihistamine that has been used for migraine
prevention in children more than in adults.
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Antihistamine with antiserotonergic effects
May have some calcium channel–blocking properties
Tends to be well tolerated
Increased weight gain is the most significant side effect.
Because weight gain is substantial, use of this medication
tends to be limited to younger children
 β-Blockers have a long history of use for preventing
childhood headaches.
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Propranolol was found to provide mixed responsiveness when
used for childhood headaches.
.Tolerated best with a titration of the dose over 1-2 wk.
They cause a decrease in blood pressure.
There is a risk for exercise-induced asthma.
They can result in depressive effects
Calcium-channel blockers
 Flunarizine
Baseline headache frequency was significantly reduced
in flunarizine-treated children. not scheduled to be
approved in the United States
• Verapamil: drug has not been FDA approved for use in
migraine
Biobehavioral therapy
 Essential for children to maintain a lifetime response to the
treatment and management of their headaches .
 Treatment adherence
Clear understanding by the patient and parent about the
importance of the treatment is essential.
 Biofeedback-assisted relaxation therapy
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For children, single-session biofeedback-assisted relaxation therapy has
been demonstrated to be learned quickly and efficiently
 Relaxation techniques with biofeedback of either cutaneous
temperature with a finger probe or muscular contraction with an
electromyography (EMG) needle are very helpful as adjunct therapy
or can even prevent headache on their own in the older child
granted that an adequate cooperation can be obtained.
 Recommended treatment is 2-3 times a week for 4-8 weeks. Usually,
a physical therapist or sometimes a psychologist with cognitivebehavioral skills performs this technique.
Lifestyle changes
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Adequate fluid hydration, with limited use of caffeine
Regular exercise
Adequate nutrition through regular meals and a balanced diet
Adequate sleep
The patient and parents must understand that these objectives
are lifetime goals that can control the effect of migraines and
minimize the use of medication.
Lifestyle changes may result in an overall long-term
improvement in quality of life and may reverse any progressive
nature of the disease.
When to refer
 Headaches that do not respond routinely to acute
treatment
 Headaches that are increasing in frequency, severity, or
duration
 Headaches in which the features acutely change
 Side effects of medications that limit increasing the
medication to an effective dose
 Psychological factors that interfere with management
 Disability that impairs functioning
Follow up
 Important to assess regularly the morbidity of headaches
and effectiveness of treatment
 Regular measurement of both disability and quality of life
are helpful in assessing treatment strategies and
improvement in outcomes.
 Disability
 Pediatric Migraine Disability Assessment (PedMIDAS) uses a
patient-based disability scale.
 Quality of Life
 Pediatric Quality of Life Inventory version 4.0 (PedsQL 4.0) uses
both parent and child input.
 Evaluates functioning in health, emotional, social, and school
domains
 Headaches have been found to substantially affect emotional
development and school functioning.
PEDMIDAS
Developed to assess migraine disability in pediatric and
adolescent patients
validated for ages 4 to 18
Pedmidas score
Disability grade
0 to 10
little/none
11 to 30
mild
31 to 50
moderate
> 50
severe
A 16-year-old girl who is new to your practice complains of a nearly
constant headache for the past year. She describes the pain as a
band around her head that often is throbbing and is worse during
the middle of the day. She denies nausea or vomiting but reports
occasional fatigue. There is no family history of headaches. She has
missed more than 20 days of school this year because of the
headache, and she is struggling to maintain a C average. She
admits to hating school and does not participate in extracurricular
activities because she "doesn't like anything." Findings on her
physical examination, including complete neurologic and
funduscopic evaluation, are normal.
Of the following, the BEST next step in the management of this
girl's headaches is to
Of the following, the BEST next step in the management
of this girl's headaches is to
A. advise her to keep a headache diary and return in 2
B.
C.
D.
E.
months
obtain a lumbar puncture
obtain computed tomography scan of the brain
prescribe oral sumatriptan
refer her for psychosocial evaluation and counseling
 A 14-year-old girl who has a 1-year history of migraine
headaches presents to the emergency department with a
severe headache that she calls "the worst headache of my
life. " The headache occurred suddenly after she lifted a
heavy box. Her mother says that the girl has been holding
her head stiffly. On physical examination, she appears in
severe pain and has meningismus. Other findings on the
physical examination are normal.
Of the following, the MOST appropriate initial course of
action is
Of the following, the MOST appropriate initial course of
action is
A. emergent noncontrast head computed tomography
B.
C.
D.
E.
scan
intravenous administration of ceftriaxone
intravenous administration of dihydroergotamine
lumbar puncture
oral administration of sumatriptan