1 / 62

My Head Hurts! Assessment and intervention in school

My Head Hurts! Assessment and intervention in school. Don Lewis, MD CHKD/EVMS. Outline: case-based format. Introduction Videos Diagnosis Evaluation Management Acute Preventative. Impact of Headache. Highly significant health problem

omer
Download Presentation

My Head Hurts! Assessment and intervention in school

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. My Head Hurts!Assessment and intervention in school Don Lewis, MD CHKD/EVMS

  2. Outline: case-based format • Introduction • Videos • Diagnosis • Evaluation • Management • Acute • Preventative

  3. Impact of Headache Highly significant health problem > 45 million Americans suffer fromchronic recurrent headaches, > 30 million Dx with migraine 43 million suffer from asthma, diabetes and coronary heart disease combined

  4. The FIRST step: MAKE THE CORRECT HEADACHE DIAGNOSIS !

  5. Chief complaint: “I think he’s got my migraines?”

  6. Was that headache, a migraine? Why or Why not?

  7. Introduction • Diagnosis of the primary headache disorders rests on clinical criteria defined by the ICHD. • Identification of secondary causes of headache are uncovered by this systematic process of history and physical. “The principle indication for performance of ancillary diagnostic testing rests upon information or concerns revealed during this fundamental process ” !

  8. Headache Assessment History PE MRI or CT Primary Secondary • Migraine • Tension • Chronic Daily

  9. “Headache” history • How long have the headaches been occurring? • < or > 6 months ? • What is the temporal pattern? • ACUTE • ACUTE-RECURRENT (episodic)* • CHRONIC PROGRESSIVE • CHRONIC NON-PROGRESSIVE • aka Chronic daily headache

  10. SYMPTOMS TIME days days 4 temporal patterns of pediatric headache

  11. Brain Tumor HeadachesLength of Illness Brain tumor headaches are associated with neurologic findings in 85% of cases within 8 weeks of headache onset and in virtually all cases by 24 weeks. Am J Dis Child 1982:136;121-124.

  12. Headache characteristics minutes hours days weeks • Frequency and duration • Location • Quality of pain • Warning signs or promontory features • Associated symptoms • Aggravating factors

  13. Headache characteristics • Frequency and duration • Location • Quality of pain • Warning signs or promontory features • Associated symptoms • Aggravating factors frontal orbital temporal occipital !

  14. Headache characteristics • Frequency and duration • Location • Quality of pain • Warning signs or promontory features • Associated symptoms • Aggravating factors pounding stabbing pressure

  15. Headache characteristics • Frequency and duration • Location • Quality of pain • Warning signs or promontory features • Associated symptoms • Aggravating factors Age < 3 Waking HA Waking Vomiting Vomiting > Nausea Aggravating factors Altered Mental Status

  16. Headache characteristics • Frequency and duration • Location • Quality of pain • Warning signs or promontory features • Associated symptoms • Aggravating factors nausea/vomiting sensory photo/phonophobia motor

  17. Headache characteristics • Frequency and duration • Location • Quality of pain • Warning signs or promontory features • Associated symptoms • Aggravating factors stress lifting straining coughing

  18. HeadacheHistorical Features Pattern(acute, recurrent, progressive, non-progressive) Length of illness(acute vs. chronic) Frequency, duration Location (holocephalic, bifrontal, unilateral, posterior) Quality of pain (throbbing, stabbing, pressure) Time of day (wakes from sleep, early Morning) Associated Features Nausea, vomiting, abdominal pain Visual aura, diplopia Photo / phonophobia Vertigo, dizziness Motion sickness, nocturnal leg cramps

  19. The NEUROLOGICAL EXAM.

  20. 5key features of neurological exam • Optic discs • Eye movements • “Pronator” drift • Tandem gait • Deep tendon reflexes • 99% of kids with BAD stuff have 1 of these signs Neuro-Macarena

  21. Chronic progressive pattern Quality: squeezing Changing quality & severity Increased with cough Neck stiffness Absence of autonomic features No photophobia No phonophobia “Fuzzy” vision Double vision Head tilt Obesity Rx: Acne meds Thyroid meds Normal CAT scan DIAGNOSIS Why is Ben’s headache NOT migraine?

  22. LP: Opening pressure ~ 400 mm H2O 2 WBC Glucose 60 Protein 10

  23. Idiopathic Intracranial Hypertensionaka: Pseudotumor cerebri

  24. The FIRST step: MAKE THE CORRECT HEADACHE DIAGNOSIS !

  25. So… to scan or not to scan… • Headache diagnosis & normal exam - NO • Worrisome history, no clear diagnosis - YES • Abnormal exam - YES • Seizures - YES

  26. HeadacheCase 1 A 7-year-old boy presents with a two-month history of increasing holocephalic headaches, and then two weeks of diplopia and clumsiness. Exam reveals normal fundi but there is a left esotropia, mild left motor neuron facial palsy, head tilt to the left, and minimal right extremity weakness. Head circumference is 52.5 cm (75 %). ?

  27. Headache Assessment History PE MRI or CT Primary Secondary ? - A ? - B

  28. Diagnosis?

  29. Tension-type headache • > 10 episodes • Duration 30 minutes - 7 days • 2 of the following: • Bilateral location • Pressure quality • Mild – moderate intensity • Not aggravated by activity • Absence of nausea, photo/phonphobia

  30. How would you treat him? • NSAID • Sumatriptan • Indomethacin • Acetaminophen • Stress management

  31. Tension-type Headache Non-progressive Limited data in children Prevalence approx 18 % Infrequently presents for evaluation Management: OTC agents CAM Therapies Relaxation Cognitive Behavioral Therapy Acupuncture

  32. Diagnosis?

  33. Childhood Migraine without AuraIHS-R Criteria – 2004* • 5 or more lifetime headache attacksbetween 1- 72 hr in duration • Any 2 of the following 4: • Unilateral temporal or bilateral frontal • Throbbing or pulsatile pain • Moderate or severe intensity • Aggravated by routine physical activity • Any 1 of the following 2: • Nausea and/or vomiting • Photophobia and/or phonophobia *Olesen J. The International Classification of Headache Disorders (2nd Edition). Cephalgia 2004; 24 (Suppl 1):9-160.

  34. The Migraine Attack Associated Features Prodrome Aura Headache Postdrome Time Intensity of Symptoms or Phases HEADACHE

  35. Prevalence of migraine w/o aura Stewart, Linet et al. Am J Epidem. '91

  36. Diagnosis?

  37. Migraine without aura Migraine with aura typical aura aura without headache familial hemiplegic Types 1, 2, 3 sporadic hemiplegic basilar-type Periodic syndromes of childhood that represent precursors of migraine Benign paroxysmal vertigo Cyclic vomiting Abdominal migraine CLASSIFICATION -- ICHD ‘04

  38. Non-Pharmacologic Pharmacologic MIGRAINE MANAGEMENT

  39. Management options • Non-Pharmacological • CONFIDENT REASSURANCE !! • LIFESTYLE • EXERCISE • SLEEP HYGIENE • TRIGGERS • BEHAVIORAL THERAPIES • BIO-FEEDBACK • STRESS MANAGEMENT • BAN SMOKING & Moderate CAFFEINE !!

  40. Rx: MANAGEMENT • Pharmacological • ANALGESIC • PROPHYLACTIC • ANTI-EMETIC • “Alternative” measures

  41. acetaminophen* ibuprofen* naproxen triptans* ketorolac ergots (DHE) combinations butalbital plus isometheptane Analgesics

  42. When using analgesics; REMEMBER !!!! • GIVE ENOUGH • GIVE EARLY within 30 minutes • NOTE LENGTH OF USUAL ATTACK • don’t use a 4 hour med for 8 hour headache • MAKE Rx AVAILABLE • AVOID NARCOTICS • analgesic overuse...

  43. Ibuprofen works in < 1 hour p=0.006 * * cumulative responders (%) time (min)

  44. The TRIPTANS in children • sumatriptan*# Imitrex sq-po-nasal • zolmitriptan*# Zomig po-odt-nasal • naratriptan* Amerge po • frovatriptan Frova po • rizatriptan*# Maxalt po-mlt • eletriptan * Relpax po ALMOTRIPTAN*# Axert po • ** studies in children demonstrating safety • # studies in children showing efficacy…maybe

  45. Triptans: Give early, within 30 minutes • Toxicities: • Chest pressure • Neck and facial tingling • Flushing • Drowsiness • Dizziness • Nasal sprays bad taste • Serotonin syndrome: • Confusion, dysautonomia, movement disorder

  46. Nasal sprays

  47. An ounce of prevention is worth a pound of cure.Benj. Franklin Establish the headache BURDEN.

  48. Preventative agents • Majority of children do not need daily preventive Rx < 30% warrant prophylactics • 3 headaches/month to justify daily Rx • TREAT DURING SCHOOL YEAR… • Start low, go slow • Growing controlled evidence in kids…

  49. Cyproheptadine Amitriptyline Anticonvulsants valproic acid topiramate gabapentin Beta-blockers Calcium channel blockers Non-steroidal anti-inflammatory agents Available prophylactic agents

More Related