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Pediatric Headaches Stephen Deputy, MD FAAP

Pediatric Headaches Stephen Deputy, MD FAAP. Case #1. 14 y.o. female patient with a 2 year history of headaches that have been increasing in intensity and frequency for the past 4 months. Case #1 Headache Defining Questions. Location : Quality : Associated “Autonomic Features :

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Pediatric Headaches Stephen Deputy, MD FAAP

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  1. Pediatric HeadachesStephen Deputy, MD FAAP

  2. Case #1 14 y.o. female patient with a 2 year history of headaches that have been increasing in intensity and frequency for the past 4 months

  3. Case #1Headache Defining Questions • Location: • Quality: • Associated “Autonomic Features: • Aggravatedby: • Improved with: • Duration: • Family History:

  4. Case #1Headache Defining Questions • Location: Hemicranial • Quality: Pounding • Associated “Autonomic Features: Phonophobia, Nausea, Dizziness, and scalp tenderness (no photophobia). No visual or sensory aura. • Aggravated by routine physical activity, improved with rest and with sleep • Duration: 2 to 8 hours • Family History: Mother and maternal aunt have “stress headaches” which occur often with menses

  5. Case #1Headache Management Questions • Frequency: • Severity: • Medication: • Triggers:

  6. Case #1Headache Management Questions • Frequency: 2 to 3 times per week on average • Severity: Most headaches are described as severe with associated missed school and social functions • Medication: Tylenol 500 mg: No help. Ibuprofen 400 mg partially reduces severity. 1° Care MD gave script for Vicodin 7.5/500 which puts her to sleep within one hour. No access to meds at school • Triggers: Menses, stress, hot weather. Drinks one to 3 caffeinated beverages per day.

  7. Case #1Physical Examination • Vitals: • HEENT: • C/V: • Neurological Examination:

  8. Case #1Physical Examination • Vitals: BP = 125/65, P= 90, BMI = 28 • HEENT: No sinus percussion tenderness, TM’s clear, full ROM of jaw and neck • C/V: RRR no murmors • Neurological Examination: • Visual Acuity • Fundoscopic Exam • EOM’s • Tandem Gait • Screening Exam

  9. Case #1Diagnosis ???

  10. Case #1Diagnosis Common Juvenile Migraine

  11. Case #1Diagnostic Work Up • CBC: ? • CMP: ? • ESR, CRP, ANA: ? • TFT’s: ? • U Tox: ? • EEG: ? • LP: ? • CT of Brain: ? • MRI of Brain: ?

  12. Case #1Diagnostic Work Up A history consistent with migraine and a non-focal neurological exam without signs of raised ICP are all that are necessary for the diagnosis of migraine • 1. Obtaining a neuroimaging study on a routine basis is notindicated in children with recurrent headaches and a normalneurologic examination (Level B; class II and class III evidence). • 2. Neuroimaging should be considered in children with an abnormalneurologic examination (e.g., focal findings, signs of increasedintracranial pressure, significant alteration of consciousness),the coexistence of seizures, or both (Level B; class II andclass III evidence). • 3. Neuroimaging should be consideredin children in whom thereare historical features to suggestthe recent onset of severeheadache, change in the type of headache,or if there are associatedfeatures that suggest neurologicdysfunction (Level B; classII and class III evidence). Neurology2002;59:490-498

  13. Case #1Treatment Acute Symptomatic Rx Daily preventative Rx ? ?

  14. Case #1Treatment Acute Symptomatic Rx Daily preventative Rx • Right Drug • Right Dose • Right Timing of Administration • At least 2 to 3 disabling headaches per week • Headaches that are poorly responsive to optimal Acute Symptomatic Rx

  15. Case #1Treatment Acute Symptomatic Rx Daily preventative Rx • NSAIDS • Triptans • Ergotamines • Aspirin/Caffeine compounds • Dopamine Antagonists • Tylenol • Narcotics have no antimigraine properties and should be avoided whenever possible • TCA’s • Ca++ Channel Antagonists • Anticonvulsants • Cyproheptadine • Propranolol, while widely perscribed is poorly tolerated and not necessarily any more effective

  16. Case #1Treatment (Continued) Modifying Triggers • Good Sleep • Healthy Eating • Regular exercise • Minimize caffeine usage • OCP’s for refractory catamenial migraine

  17. Case #2 17 y.o. female with a 10 year history of headaches that have been daily for the past 18 months or so

  18. Case #2Headache Defining Questions • Location: • Daily time course: • Migrainous features with peaks: • Progressive: • Remote history of common migraine:? • Number of school days missed or work activities missed:?

  19. Case #2Headache Defining Questions • Location: Holocephalic, nuchal • Daily time course: Daily from awakening until sleep • Migrainous features with peaks: 2-3 hour peaks with phonophobia and dizziness (no photophobia, no vomiting, moderate in intensity) • Progressive: No • Remote history of common migraine: Yes • Number of school days missed or work activities missed: 17 days missed this year

  20. Case #2Headache Management Questions • Acute Symptomatic Treatment • What is being used • What is the dose • How often • administered • Caffeine Usage • Exercise, sleep, eating patterns • Other pain symptoms • Any depression or anxiety symptoms • Psychosocial functioning

  21. Case #2Headache Management Questions • Acute Symptomatic Treatment • What is being used: Migraine Excedrine • What is the dose: Two tabs • How often administered: Three times daily • Caffeine Usage: 4 to 6 beverages daily • Exercise, sleep, eating patterns: No exercise, overweight, insommnia • Other pain symptoms: Multiple arthralgias. Dx’d with fibromyalgia and chronic GI pain • Any depression or anxiety symptoms: Anxiety symptoms exist • Psychosocial functioning: Poor grades due to absences

  22. Case #2Physical Examination • Vitals: • HEENT: • C/V: • Neurological exam:

  23. Case #2Physical Examination • Vitals: BP = 135/78, P = 86, BMI = 42.7 • HEENT: Normal • C/V: RRR no murmurs • Neurological exam: Non focal. No signs of raised ICP

  24. Case #2 Diagnosis ???

  25. Case #2 Diagnosis • Chronic Daily Headache • Transformed Migraine Headache • Medication overuse Headache

  26. Case #2Treatment • Medication management • Taper off Acute Symptomatic Treatment • Taper off caffeine usage • Start Daily preventative therapy • PRN NSAIDs with limit one dose/day and 3 doses per week • Goal of keeping the patient functional despite daily pain • Importance of exercise, diet, and sleep

  27. Case # 3 A 10 y.o. boy with a two month history of daily headaches

  28. Case #3Headache Defining Questions • Location: • Autonomic Symptoms: • Time course of Headaches: • Progressive: • Exacerbating factors: • Relieving factors: • Neurological Deficits: • Visual Symptoms: • Constitutional Symptoms:

  29. Case #3Headache Defining Questions • Location: Holocephalic • Autonomic Symptoms: Repetitive Vomiting upon awakening, then clears. No anorexia. • Time course of Headaches: Daily and progressive without pain-free intervals • Progressive: Yes • Exacerbating factors: Supine posture, valsalva, cough, sneeze, bending over • Relieving factors: Recumbent posture, not moving head • Neurological Deficits: None reported • Visual Symptoms: Diplopia without visual obscurations • Constitutional Symptoms: No fever, weight loss, fatigue.

  30. Case #3Physical Examination • Vitals: • HEENT: • C/V: • Neurological Exam:

  31. Case #3Physical Examination • Vitals: BP = 120/58, P = 80, BMI = 24 • HEENT: No sinus percussion tenderness, neck with full ROM, no proptosis, TM’s clear • C/V: RRR without murmur • Neurological Exam: • MS: Alert, speech fluent/articulate, nl concentation and STM • CN: VA = 20/20 OS, 20/25 OD, PEERLA, fundoscopic exam with…

  32. How about this one?

  33. Case #3Physical Examination • Vitals: BP = 120/58, P = 80, BMI = 24 • HEENT: No sinus percussion tenderness, neck with full ROM, no proptosis, TM’s clear • C/V: RRR without murmur • Neurological Exam: • MS: Alert, speech fluent/articulate, nlconcentation and STM • CN: VA = 20/20 OS, 20/25 OD, PEERLA, fundoscopic exam with Bilateral mild-moderate papilledema, cannot fully abduct OS otherwise EOMI, face symmetric, palate and tongue midline • Motor:Nl tone, strength, symmetric DTR’s, downgoing toes • Sensory:Nl light touch, cold and vibration sense • Coordination: No dysmetria or tremor or titubation • Gait: Normal narrow-base gait. Tandem gait intact

  34. Case #3Diagnosis ???

  35. Case #3Diagnosis Raised Intracranial Pressure Due to… • Pseudotumor Cerebri • Hydrocephalus • Brain Tumor • Brain Abscess • Venous Sinus Thrombosis

  36. Case #3Diagnosis The Next Step?

  37. Case #3Diagnosis Neuroimaging • Urgent CT vs • MRI with MR Venogram

  38. Case #3Diagnosis The Next Step?

  39. Case #3Diagnosis Lumbar Puncture • Opening Pressure • Cell Count with Cytology • Protein and Glucose

  40. Case #3Diagnosis Lumbar Puncture • Opening Pressure: 380 mmH2O • Cell Count with Cytology: 2 WBC (70% monocytes). No malignant cells. • Protein and Glucose: Protein = 24 mg/dl, glucose 80 mg/dl (serum = 120 mg/dl)

  41. Case #3Diagnosis Pseudotumor Cerebri • Treatment ?

  42. Case #3Diagnosis Pseudotumor Cerebri • Medication Treatment • Acetazolamide • Other Diuretics • Glucocorticosteroids • Optic nerve Sheath Fenestration • Ophthalmology Follow Up • Visual Field Testing • Headache Evaluation

  43. Now get out there and treat headaches with confidence. Stop unnecessary neuroimaging. Develop a Treatment Plan! You can do it.

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