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Morning Report

Morning Report. Lorrie Edwards Pediatric Chief Resident July 8 th , 2013. The Case. “I have a terrible headache”. History. SR is a 10 yo boy presenting with 2 days of progressively worsening headache. The headache is bifrontal , 7/10 and was sudden in onset

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Morning Report

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  1. Morning Report Lorrie Edwards Pediatric Chief Resident July 8th, 2013

  2. The Case “I have a terrible headache”

  3. History • SR is a 10 yo boy presenting with 2 days of progressively worsening headache. • The headache is bifrontal, 7/10 and was sudden in onset • It was associated with photophobia and R eye pain • He had mild nausea, but no vomiting. • A few hours later he developed dizziness and diplopia and had some change in his gait, so his mother brought him to the ED. • ROS: No recent fevers, no GI symptoms, no seizure, no LOC. • PMH: Has had occasional headaches for the last 2 years. They are usually on the right side and resolve with ibuprofen. Also history of asthma – takes Albuterol PRN.

  4. Differential?

  5. Physical Exam • T 36.3, HR 80, RR 20, BP 96/54, SaO2 99% • Gen: Uncomfortable and anxious • HEENT: NCAT. PERRL. 2 beats of horizontal nystagmus. TMs clear. OP clear. • Lungs: CTABL • Cardiac: RRR, S1/S2, no murmur • Abd: Soft, NTND, no HSM • Neuro: A&O x 3. CN: Possible R sided facial droop (per mom, this is baseline). Normal speech. Sensation intact. 5/5 strength in all extremities. Dysmetria on R FNF test. Gait – staggering. Normal DTRs.

  6. Imaging and Studies • CBC: 11>11.7/34.8<282 • Chem: WNL • UTox: WNL • LP: No polys, no organisms. WBC 2, RBC 1, Protein 20, Glucose 69 • Brain MRI: No mass is seen. No thrombosis of central venous draining veins. There is a left parietal periventricular/ependymal focus of gray matter heterotopia (can be normal, or associated with seizures).

  7. Hospital Course • SR was evaluated in the ED and found to have some dysmetria on cerebellar tests, as well as some truncal ataxia. He had an urgent MRI which ruled out acute bleed, infarct, or mass. LP was WNL • He was treated with a headache cocktail of Reglan/ Toradol /Benadryl, after which his symptoms resolved, including his ataxia. • Differential diagnosis included Miller-Fisher variant of Guillain-Barre and migraine. EMG studies were normal, ruling out Miller-Fisher. Given his clinical improvement, a diagnosis of migraine headache was made.

  8. Migraine • Describing the headache • Unilateral (60-70% • Bigrontal or global (30%) • Gradual onset • “throbbing” • Worse with motion, better when lying still. • More common in boys than girls…until puberty. Then more girls than boys. • By age 17 years, 8% of males and 23 % of females

  9. Migraine • Three of the following criteria should be present for the diagnosis of childhood migraine • Abdominal pain, nausea, or vomiting with headache • Hemicrania (unilateral headache) • Throbbing, pulsating pain • Complete relief after a brief rest • An aura, either visual, sensory, or motor • A history of migraine headaches in one or more family members

  10. Classification • Migraine without aura • Migraine with aura • Ophthalmic • Hemiparesthetic • Numbness and tingling of the lips, lower face, and fingers of one hand • Hemiparetic • Hemiplegic • Can be familial or sporadic • Aphasic • Basilar migraine • Aura affects the brainstem or cerebellum • Ophthalmoplegic migraine • Menstrual migraine

  11. When to image? • Rapidly increasing headache frequency • History of lack of coordination • History of localized neurologic signs or subjective numbness or tingling • History of headache causing awakening from sleep

  12. Pathophysiology • There is no one theory that explains all the symptomatology of migraines. It is clearly polygenetic and multifactorial. • Current evidence points to: • Primary neuronal dysfunction • Genetic predisposition • Environmental triggers • Imbalance in activity between brainstem nuclei regulating antinociception and vascular control • Serotonin dysregulation in its role in central pain control pathways and vascular function

  13. Treatment Abortive Prophylactic Headache diary Reduction of stress, environmental triggers Ciproheptadine Propranolol Valproate Topiramate Gabapentin Amitriptyline • NSAIDs • Ibuprofen or naproxen • Ketorolac • Tryptans (serotonin agonists) • Oral or nasal sumatryptan • Nasal zolmitryptan • Use in children is often off-label • Sumatryptan + Naproxen • Antiemetics • Promethazine • Ondansetron • Reglan • IV meds • Ketorolac • Dihydroergotamine • Valproate • Metoclopramide

  14. PREP A 12 yo 40kg girl presents for a health supervision visit. Physical examination, including vital signs, yields normal results. The mother notes that the girl had to come home from school three times last semester due to headaches. Her typical headaches are bifrontal, with sensitivity to light and sound and often nausea. They last 1 to 6 hours. During the headache, she feels and looks sick and prefers to lie in a dark room. The mother requests an acute treatment plan for her daughter. You provide education about migraine headaches and discuss lifestyle issues, including good sleep hygiene, exercise, diet, hydration, and stress management. For abortive headache treatment, you explain that it is ideal to treat within 30 minutes, even at school. Of the following, the PREFERRED abortive treatment for this girl is: • A. butalbital (50mg), acetaminophen (325mg), caffeine (40mg) orally • B. ibuprofen (400mg) orally • C. promethazine (12.5mg) rectally • D. sumatriptan (5mg) intranasally • E. topiramate (25mg) orally

  15. PREP A 12 yo 40kg girl presents for a health supervision visit. Physical examination, including vital signs, yields normal results. The mother notes that the girl had to come home from school three times last semester due to headaches. Her typical headaches are bifrontal, with sensitivity to light and sound and often nausea. They last 1 to 6 hours. During the headache, she feels and looks sick and prefers to lie in a dark room. The mother requests an acute treatment plan for her daughter. You provide education about migraine headaches and discuss lifestyle issues, including good sleep hygiene, exercise, diet, hydration, and stress management. For abortive headache treatment, you explain that it is ideal to treat within 30 minutes, even at school. Of the following, the PREFERRED abortive treatment for this girl is: • A. butalbital (50mg), acetaminophen (325mg), caffeine (40mg) orally • B. ibuprofen (400mg) orally • C. promethazine (12.5mg) rectally • D. sumatriptan (5mg) intranasally • E. topiramate (25mg) orally

  16. References • Weiller C, May A, et al. Brain stem activation in spontaneous human migraine attacks. Nat Med. 1995;1(7):658. • Prensky AL, SommerD. Diagnosis and treatment of migraine in children. Neurology. 1979;29(4):506. • Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9. • Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754.

  17. Thank You!

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