Headaches in Childhood Maura B. Price MD FAAP FRCPC February 2010

Patients see a physician for headache either because of pain or reassurance

Epidemiology 50% occasional headaches 7% frequent headaches 4% migraines 40%nil

History Pain type Precipitating/relieving factors Associated symptoms Frequency and duration Impact Time of day Changing or worsening How many kinds of headaches

Physical Vitals including blood pressure Neuro Exam Head and Neck Exam

Classification AcuteAcute, Recurrent Chronic, ProgressiveChronic, Non-progressive

Acute Infection systemic vs CNS Poisoning lead or CO Anemia Hypertension Hypoglycemia Trauma Emboli Hemorrhage Post seizure

Acute Recurrent Common migraine without aura 60-85% Classic migraine with aura % Migraine variants

Criteria for Migraine without aura A.At least 5 attacks fulfilling B-D B.Duration 1-48 hours C.Headache that has at least 2: unilateral or bilateral pulsatile moderate to severe intensity worse with physical activity During headache at least 1: nausea or vomiting or phonophobia or photophobia

Criteria migraine with aura A.At least 2 headaches fulfilling B. B.At least 3 of following:- -one or more fully reversible aura including focal cortical or brainstem -1 aura develops over 4 minutes or 2 or more auras occurring together -no auras lasting more than 60 minutes -headache follows within 60 minutes

Migraines Family History85% Headache throbbing65% hemicranium20% GInausea/vomiting60% anorexia10% abdominal pain5% Auravisual5% numbness0.5% Assoclightheaded20% nocturnal10% 5% photophobia pallor motion sickness Periodic

Factors Precipitating Migraine Stress/anxiety Menstration Oral contraceptives Physical exertion/fatique Glare Foods with nitrites, glutamate, caffeine, tyramine or salt Hunger Perfume

Treatment of Migraines Avoid triggers Ibuprofen (10-15 mg/kg) Tylenol ( mg/kg) Naproxen sodium (Anaprox ) (10-20 mg/kg/d BID) Zofran (Ondansetron) for emesis Fiorinal/Fioricet (1-2 tabs 4/day) or Midrin Codeine +/- caffeinated soda Chlopromazine or promethazine for emesis

Abortive Therapy for Migraine Sumatriptan (Imitrex) age years 25mg or 5 mg of nasal spray (20 mg for repeat) Isometheptane (Midrin) 1-2 caps hourly 5/day Rizatriptan (Maxalt) and Zolmitriptan (Zomig) Ergots/Caffeine Dihydroergotamine for status migraine

Migraine Prophylaxis Beta-Blockers: Propanolol Tricyclics: Amitriptyline antidepressant 1 mg/kg 85% reduction in frequency but not duration side effects: sedation Cyproheptadine antihistamine (Periactin) 83% response with reduction in frequency and duration side effects: sedation and increased appetite Anticonvulsants: Topiramate, Valproic Acid and Gabapentin Naproxen sodium ( mg BID) Riboflavin (400 mg/day single dose), Mg, Feverflu

To Abort Migraines Ibuprofen or Acetominophen Promethazine 0.25 mg or Ondansetron Nasal Sumatriptan 5mg-20mg

To Prevent Migraines < 6 years Periactin 4-12mg at bedtime Older Propanolol 1mg/kg/day divided TID Heart rate > 60 after 1 min exercise Topamax especially boys mg/kg in two or three doses Mixed H/A amitriptyline 5 mg qhs Biofeedback and behavior training

Chronic Progressive Tumor, Abscess Pseudotumor Hydrocephalus Hematoma These may be associated with blurred vision, double vision or vomiting. These headaches are often worse in a.m. and worse with valsalva maneuvers

Worry Factors Sudden onset Occurs during exertion Drowsy Meningeal symptoms Focal neurologic signs and symptoms Fever Papilledema

Guidelines for neuroimaging Nocturnal or early morning headaches Progressive headaches Abnormal neurological findings on examination Focal neurological symptoms during headache except visual aura Headache with change in personality

Chronic Nonprogressive Tension Depression These are usually not CNS related

Tension Headaches At least 10 previous headaches fulfilling criteria but less than 180/year Headaches last 30 minutes to 7 days At least 2:-pressing or tightening -mild or moderate intensity (inhibit not prohibit activities) bilateral not aggravated by PE Both: -no nausea or vomiting -none or one photophobia or phonophobia

Treatment of Chronic Daily H/A Behavioral/relaxation and biofeedback OTC Acetominophen and Ibuprofen Antidepressants: tricyclics, elavil and SSRI’s