Transcript Headaches in children & New NICE Guidance

Headaches in children
& New NICE Guidance
Sreeni Tekki-Rao
April 2014
Content
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Quiz
Classification
Pathophysiology
History and physical exam
Primary headaches
NICE approach
Incidence & Prevalence
Incidence per 1000
Males
Females
Migraine with aura
6.6
14
Migraine without aura
10
18
Headaches
Age <7yrs
7-15
Prevalence
37-51%
57-82%
Serious underlying disease: 3/815 children with
headaches
Classification
Migraine
Clinical (Practical)
– Acute
Primary
Cluster
Tension
type
Headaches
Secondary
Many
causes
• General
• Focal
• Recurrent
– Chronic
• Progressive
• Non progressive
Classification -acute
• Acute General
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Fever/ infection
CNS inf
Postictal
BP
Hypoglycemia
LP
Head injury
CNS bleed
Embolus
• Acute Focal
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Sinusitis
Otitis
Pharyngitis
Glaucoma
TM joint
Dental
Occipital
neuralgia
– Trauma
Acute Recurrent
-Migraine
-Vasculitis
-AVM
-Substance abuse
-Post ictal
-Shunt related
Classification -chronic
• Chr Progressive
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Hydrocephalous
Subdural haematoma
Neoplasm
Abscess
Dandy-walker
Chiari malformation
Subdural empyoema
IIH
• Chr non-progressive
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Chr tension type
Chronic daily migraine
New persistent daily
Hemicrania continua
How does headaches occur?
(Pathophysiology)
• Sensitive extracranial structures
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Skin, S/C tissues
Muscles
Mucous membranes
Teeth
Larger vessels
• Sensitive intracranial structures
– Vascular sinuses
– Large veins
– Dura around the sinuses, arteries,
base of brain
Inflammation,
irritation, traction,
dilatation of these
structures
5th, 7th, 9th 10th, upper
cervical
Refer to face, top of
head, back of the
head, neck
Pathophysiology
• Migraine
– Vascular theory
• Cerebral ischaemia – aura
• Extracranial vaso
dilatation – pulsating
head ache
– Trigemino-vascular
theory
• Depolarisation of cortical
neurons
• Tension type
– Genetic
– Muscle mechanisms
– Central/peripheral
sensitization
– Unclear
• Cluster
Headache
-Hormones
-Hypothalamus
-Cingular cortex
Genetics and headaches
• Classic Migraine: First degree relative
• Migraine without aura: Multifactorial
• Familial hemiplegic migraine: AD
– Mutations voltage gated ca+ channels
• CACNA1A, ATP1A2
Evaluation
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How many types of headache?
When did it start (Duration)
How did it begin?
How often do they occur?
Becoming more severe?
Does anything special bring them
on?
Can you preempt 15-30 min
before?
Where is the pain?
What does your pain feel like?
What do you do when you get
one?
What makes it worse/better?
• Do you take anything?
• How long does it last?
• Has any other family member got
it?
• Any other medical problems?
• Are you taking any medications
regularly?
• Any neurological symptoms in
between headaches?
• How many days of school missed?
• How often do you take medicine to
relieve headache?
• What do you think is causing this
headache?
Enquire…
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Sx of raised intracranial pressure
Progressive neurological disease
Quality of life
Impact on daily activities
Educational performance
Change in behaviour/personality
Clarify..
Terms: “Throbbing”, “Pulsatile”
Concept: Five sides to head?
Physical exam
• General:
– Temp, BP, short stature, NC markers
– Tenderness over scalp/skull
• Neuro
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Nuchal regidity
Trauma signs
OFC
Bruits
Motor eye movements
Fundus
Symmetry of reflexes
Fogg test
Red Flag features
• Headache worse in recumbency, or with
cough/strain
• Headache waking up child
• Confusion +/- morning nausea or vomiting
• Recent change in personality, behavior,
educational performance
• Physical signs: field defect, short stature,
cranial bruit, raised ICP
Scenario 1
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Intermittent headaches
Nausea, vomiting
Pain free intervals
No neuro symptoms/signs
+ve family history similar headaches
Migraine
Scenario 2
• Relatively short history
• Worsening headaches over time
• +ve neuro symptoms and signs
Chronic Progressive
Headache
Investigate!!
Scenario 3
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Severe headache
Appears to be not in stress due to headache
No raised ICP features
Normal neuro exam
Chronic non
progressive (tension type)
Episodic Migraine
• Episodic, Periodic,
paroxysmal
• Throbbing
• Uni/bilateral
• Duration: 30min to days
• Attacks separated by pain
free intervals
• Pallor, beh changes
• Relieved by sleep
• Boys>girls (before
teens)
• Begins early in life
• Teenagers
– Early morning
– Awakening the child
• Young kids
– mid afternoon
Migraine with aura (Classic)
• Aura
– Nausea, vomiting, abd pain
– Visual disturbances
• Scotoma moving across fields
• Blurring, hemianopia
• complete blind in one eye (amurosis fugax)
– Numbness, tingling in one arm/side
– Hemiplegia
– Aphasia, apraxia
Aura
Criteria
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Migraine with Aura (Classic) – 17%
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At least 2 attacks lasting 1-72 hours
Migraine aura
Not attributed to another cause
Migraine without aura (Common) – 60%
A.
B.
C.
At least 5 attacks of B-D
Head ache lasts 1-48hrs
Headache has at least 2 of
a. bilateral/unilateral (frontal/temporal)
b. Pulsating
c. Moderate to severe
d. Aggravated by routine physical activity
D. During headache
a. Nausea and/or vomiting
b. Photophobia and /or phonophobia
Complicated migraine
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Basilar artery migraine
Hemiplegic
Ophthalmoplegic
Migraine variants
– Benign paroxysmal vertigo
– Benign paroxysmal torticollis
– Abdominal migraine
– Cyclical vomiting
Basilar artery migraine
• Dysfunction of
– brain stem, cerebellum, parieto-occipital and inferotemporal cortex
• C/F:
– Preceded by Vertigo, tinnitus, dysarthria, ataxia,
diplopia
– Blurred vision, tunnel vision, visual field defects,
parasthesia, dizziness, hemipareisis, quadriperesis,
aphasia, loss of conciousness
– Headaches not severe – occipital
• Duration 1-several hrs
• Recovery complete
• Common in females
Other headache syndromes
• Occipital neuralgia: uni/bilat posterior, infrequent to
continuous
• Temporal mandibular joint: Dull aching pain
unilateral below ear
• Exertional headache: Cough, sneeze, laugh, sports
• Hemicrania Continua: steady, severe, frontal, no
nausea, response to indocid
• Ice cream headache: Cold induced
• Ice pick headache: single sharp jabbing over
orbit/temple/parietal
Chronic Tension-type
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No aura, Less severe
Bifrontal/ bitemporal, nonsepcific description
Rarely: Nausea/vomiting
Mild blurring, fatigue,dizziness
Frequency: 15 times/month
Normal neurology
Excessive school absence, overuse of analgesics
Cluster Headache
• Episodic/Chronic
• Episodic: Frequent last 1-3months with remission
months to yrs
• Chronic: >1 yr with out remission
• Males>females, not common in children
• Attack: typical 10min-3hrs, waking from sleep,
unilateral, around eye, lacrimation, rhinorrhoea,
nasal stuffiness, ptosis/miosis
Cluster headache
Investigations – if appropriate
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CT head
Fundus/perimetry by ophthalmologist
MRI
MRV/MRA
LP/Infusion study
Psychological evaluation
EEG – Not recommended if migraine is
suspected (AAN)
Management all headaches-NICE
• Headache diary -8weeks
• Investigate
– if red flags
– No neuroimaging, if primary headache is diagnosed
• Discussion with pt/parents
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Positive diagnosis
Options of treatment
Recognition that it is a valid medical disorder
Written information
Explain risk of medication
Migraine Treatment
• Phramacologic vs Non pharmacologic
• Symptomatic vs Prophylactic
• Rx depends
– Age
– Severity
– Frequency of attacks
– Attitude for Rx
– Assurance may suffice
Non pharmacologic Rx
• Patient/parent education
• Eliminating triggers (cows milk, egg,
chocolate, orange wheat, benzoic acid,
cheese, tomatos, rye)
• Regular diet, sleep, exercise
• Counseling
• Biofeedback
Symptomatic Rx
• NSAID most useful than paracetamol
– Ibuprofen, Naproxen, Phenacetin, Caffeine
• Triptans (Sumatriptan spray) – not licenced
• Antiemetics
(Cyclizine,domperidone,ondansetran)
• Sedatives
• Ergotamines – not children
• Antihistamines
Prophylactic
– Cyproheptadine
• H2 and serotonin receptor antagonist
– Pizotifen
• Betablockers
– Propranolol (1 mg/kg up to 10mg BD)
– Atenolol (0.8-2mg/kg/day)
• TCA (Amitryptiline)
• Anticonvulsants
– Valproate, Topiramate (50-100mg), Levetiracetam (1g)
• Calcium channel blockers
– Verapamil, Nifedipine, Flunarazine (5 mg/day)
Evidence for prophylaxis
• Pizotifen
– RCT placebo crossover, 47 children, 7-14yrs
– Did not reduce number of episodes, mean
duration
• Propronolol
– 3 trials placebo controlled (1 effective, 2 no
difference, 3 not effective)
– Systematic review (58 trials of all ages) – more
effective than placebo
NICE guidance - migraine
• Acute Rx
– Oral triptan + NSAID/Paracetamol
– Children 12-17yrs – Nasal Triptan
– Antiemetic (even in the absence of nausea)
• If vomiting severe rectal
– Do not offer Ergots
• Prophylaxis
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Discuss benefits and risks
Offer Topiramate/propranolol
Alternatives: 10 sessions of acupuncture/gabapentin
R/v in 6 months
Useful tips
• Acute attack:
– Rest – antiemetic – sedative (diphen hydramnine) –
Analgesic (NSAID)…
– 2 hr later: Rpt sedative, different analgesic…
– If failed above: Triptans
• Prophylactic:
– Frequent migraine unresponsive to acute measures
– Disruptive to school/other activities
Life style issues
• BNF: avoid common headache triggers
– Heat, light, noise, strong smell, lack of sleep, lack
of food, excitement, travel, exercise, types of food
• Fluctuating vulnerability
• Use common sense
Tension type headache – NICE Rx
• Acute Rx
– Aspirin/Paracetamol/NSAID
– No opioids
• Prophylaxis
– 10 sessions of acupuncture over 5-8 weeks
Cluster – NICE Rx
• Acute Rx
– O2
• 100% o2 via non-rebreathing mask @12l/min
• Home O2
– S/c or Nasal Triptan
– DONT offer
• Paracetamol, NSAIDs, opoids, ergots, oral triptans
• Prophylaxis
– Verapamil
– If unsure contact specialist
Medication overuse headache
• Consider in those taking drugs
>3mo
– 10days/mo or more of following
• Triptans, Opioids, ergots, combination
analgesics
– 15 days/mo or more of following
• Paracetamol, Aspirin, NSAID or combi
• Rx: Stop for at least 1mo
– Likely to get worse before
improvement
– Offer appropriate prophylaxis
– R/V in 4-8wks
Rational Approach
• Careful clinical assessment
• Simple understandable explanation
– Common, benign, biological phenomenon
– Don’t confuse with terminology such as Tension
headache/complicated migraine/scientific terms
• Investigate sensibly if red flag signs
• Acute attacks: Simple analgesia early, with antiemetic
• Prophylactic: for truly intrusive
Prognosis - migraine
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Excellent
Mostly does not interfere with school
70% persist into adult life
Longer periods free of symptoms
Status migrainosus
– >72hrs/ >24hrs of diasbled
– Rx: sedation, IVF, ergotamine
Questions?
Summary
• Headaches are just primary or secondary
• Careful history and evaluation to rule out
serious causes (rare)
• Remember NICE approach for diagnosis
• Explanation in simple terms & reassurance
• Offer treatment and prophylaxis
• Remember medication overuse headaches
References
• Childhood Headache;
– R Newton, Arch Dis Child Educ Pract Ed 2008;
93:105-111
• Headaches and Nonepilpestic Episodic
Disorders;
– A. David Rothner and John Menkes
Child Neurology 7th ed, chapter 15, pg 943-959
• Headaches; NICE clinical guideline 150; Issued
Sept 2012
THANK YOU