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Childhood Headache

Childhood Headache. Rachel Howells. Learning Outcomes. By the end of this session, you should be able to Differentiate primary from secondary headache Recognise and manage common primary headaches. Epidemiology. Preschool 1/3 will have had a headache Migraine headache 0-7% of population

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Childhood Headache

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  1. Childhood Headache Rachel Howells

  2. Learning Outcomes By the end of this session, you should be able to • Differentiate primary from secondary headache • Recognise and manage common primary headaches

  3. Epidemiology Preschool 1/3 will have had a headache Migraine headache 0-7% of population Schoolchildren 70% have ≥ 1 headache a year Peak at 90% at age 12-13 Prevalence of recurrent headache 20-30%

  4. Case 1

  5. Case 1 15 year old girl • Frontal headache, down neck and shoulders • 2 months • Start as soon as she rises from bed, and relieved by lying down • Missing school for 6 weeks

  6. Primary or Secondary?

  7. Case 1 Further history • Spinal surgery 3 months ago • Epidural anaesthesia Examination • Normal

  8. Low pressure headache Possible dural tap Management • Encourage mobilising • Many spontaneously resolve within 3-4 months • Short-term: Caffeine • Long-term: Epidural blood patch

  9. Primary vs Secondary Headache

  10. Primary vs Secondary Headache • 10% of headaches seen in a specialist neurology / headache clinic are secondary in origin • Population prevalence of organic disease is likely to be lower

  11. Secondary Headache Types Altered Intracranial Pressure Raised ICP Low Pressure Headaches Vascular Subarachnoid Headache (eg AVM) Dissection Vasculitis Drugs Drug effect Analgesia induced headache Central (thalamic) pain Trigeminal neuralgia Cluster headaches Local Dental Abscess Sinusitis Post head injury

  12. How to identify a secondary headache

  13. How to identify a secondary headache History Examination Brain Imaging

  14. Indications that a headache is secondary to altered intracranial pressure

  15. Indications • Timing of headache • Postural manoeuvres • Associated symptoms

  16. Morning but from sleep, before rising Morning but after getting up Raised Intracranial Pressure Low Pressure Headache Timing of Headache

  17. Getting up relieves headache Coughing and straining exacerbates it Lying down relieves headache Low Pressure Headache or Sinusitis Raised Intracranial Pressure Postural Manoeuvres

  18. Frontal headache Associations Morning vomiting Other neurology Confusion Frontal headache Associations Pain / parasthesiae across shoulders* Blocked nose, facial pain¤ Raised Intracranial Pressure Low Pressure Headache* or Sinusitis¤ Associated Symptoms

  19. Case 2

  20. Case 2 16 year old girl seen in OPD • Frontal headache • There when she wakes, gets better when she gets up • No nausea or other neurological symptoms 4 months, not getting any worse

  21. Primary or Secondary? Is this raised or low intracranial pressure?

  22. Case 2 continued Past History – nil Examination • Enlarged blind spots on confrontation • No other alteration of visual fields • Papilloedema • No ataxia, long tract signs

  23. What diagnoses need to be considered?

  24. Causes of Raised Intracranial Pressure Hydrocephalus Tumour obstructing CSF pathways Obstruction to CSF re-absorption (post haemorrhage or meningitis) Congenital (eg aqueduct stenosis) Idiopathic (Benign) Intracranial Hypertension Cerebral oedema Inflammation (ADEM, stroke) Infection (meningitis etc) CO2 retention (obstructive sleep apnoea) Metabolic (DKA, other)

  25. Idiopathic Intracranial Hypertension Aetiology unknown • Adolescent girls • Obesity, drugs, steroid withdrawal • Visual loss (10%) may be permanent and is only indication for treatment Raised intracranial pressure in the absence of space occupying lesion or obstruction to CSF flow

  26. Indications • Timing of headache • Postural manoeuvres • Associated symptoms

  27. Case 3

  28. Case 3 14 year old girl • Headache since the evening before • Single and worst headache ever • Sudden onset Vomited once at start No history of head injury / prodrome

  29. Case 3 Examination • Afebrile • No meningism • GCS 15 • Unilateral facial weakness with frontal sparing • Ipsilateral arm weakness with hyporeflexia

  30. What diagnoses should you entertain?

  31. CT brain

  32. Case 3 CT shows haemorrhage around area of left basal ganglia Patient admits to using some cocaine at a party with her 18 year-old sister

  33. More information to help you identify secondary headache History

  34. Timecourse Migraine? Single or first severe headache Recurrent severe headaches One a month 2 years without progression Bleed? Headaches all day on most days 18 months Headaches every few months then weeks then days Now every day TTH? Tumour? Severe headaches all day for 12 days 2 months ago None since Bleed?

  35. Timecourse Single or first severe headache Recurrent severe headaches One a month 2 years without progression Headaches all day on most days 18 months Headaches every few months then weeks then days Now every day Severe headaches all day for 12 days 2 months ago None since

  36. Pointers in History: Summary • Timing of Headache • Postural manoeuvres • Symptoms associated with headache • Timecourse

  37. Examination

  38. Purpose of Examination • To support your clinical impression made on history • To rule out other differentials • To adhere to many families expectations • to be taken seriously • to be able to support your view that nothing serious is going on

  39. Essential elements of Examination Conscious level Vision Acuity Fields including blind spot Extraocular movements Long tract signs Tone Power Reflexes Cerebellar signs Finger-nose test (eyes shut) Tremor Dysarthria Gait Blood pressure Fundi Bruit

  40. Case 4

  41. Case 4 8 year old boy with 10 month history of • Bi-temporal headache • Throbbing • Worse with movement / exercise • Mother says looks pale and unwell • Usually start in morning • Last all day

  42. Case 4 No family history Examination is normal

  43. Primary or Secondary? What is the most likely diagnosis?

  44. Migraine without aura

  45. Migraine headache Nerve efferents – trigeminal, vagal Meninges have pain fibres with inputs from trigeminal complex Vasodilation of meningeal vessels What causes migraine? Why do some people get migraine headaches? • Genetic • Abnormal inhibitory inputs to trigeminal nerve complex Michael Creighton

  46. Clinical Implications Abnormal inhibition to nociceptive parts of brain • Abnormal response to changes in environment eg sleep, diet, smells • Pain is exacerbated by noise and light • Headache relieved by sleep in a dark room Migraine symptoms • Pain involves the face (trigeminal) • Throbbing pain (meningeal) • Pallor and nausea (vagal) Delia Malchert

  47. Migraine Classification • Migraine without aura (commonest) • Migraine with aura • Basilar migraine • Ophthalmoplegic migraine • Alternating hemiplegia

  48. Migraine The diagnosis is a clinical one Families can be reassured by • Family history • Longevity of symptoms • Normal examination • Addressing their underlying concerns

  49. Management • Explanation • This is not a tumour • Worst in second decade of life • Most patients will get fewer headaches as they get older

  50. Management 2. Treatment of attacks • Analgesia as soon as an attack starts • Ibuprofen works best (one RCT) • May be supplemented by anti-emetic • Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)

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