1. HEADACHE IN CHILDREN

2. Do Children get a real Headache? Headache is commonly perceived as an adult ailment. Child complaining of headache is either considered to be trying to gain attention or is blamed for making an excuse to avoid school. Parents may overreact – Must be a tumour. Poor reporting on the part of the child may delay evaluation.

3. 39 percent of children have suffered headache by 6 yr. Increases to 75 percent by 15 th year Impact: School days lost Restricted extracurricular activities Poor academic performance

4. Comorbidities: Anxiety Depression Loss of self esteem Fearfulness Emotional lability or rigidity Real organic deficits created by process causing headache.

5. CLASSIFICATION SECONDARY These are caused by either structural changes in intracranial / extracranial organs or systemic illnesses. PRIMARY Migraine: Episodic, periodic, paroxysmal attacks of moderate to severe throbbing pain, separated by pain free intervals, associated with nausea, vomiting, photophobia, abdominal pain and desire to sleep. Family history 70-90% About 90% patients attending a neurology clinic for headache, have migraine. Tension type headache: Band like tightening sensation around scalp, pain in occiput and neck, worsen as the day progresses. Chronic daily headache: Any primary headache if present for more than 15 days a month for three consecutive months.

6. MIGRAINE( Hemicrania) International Headache society classification Migraine without aura (common) At least 5 attacks fulfilling the following criteria: Duration between 1 and 48 hours At least 2 of the following: – Bilateral or unilateral – Pulsating – Moderate to severe in intensity – Aggravation by routine physical activity During the headache, at least 1 of the following: – Nausea or vomiting – Photophobia or phonophobia Migraine with aura ( Classic) In addition to above criteria, at least 2 attacks fulfilling at least 3 of the following criteria: One or more fully reversible aura symptoms indicating focal cortical or brainstem dysfunction Aura developing gradually over 4 minutes, or 2 or more symptoms occurring in succession Aura lasts no more than 1 hour Pain follows aura after less than 1 hour

7. Incidence of Migraine In 50% of cases : < 20y The youngest age reported was 3y 7y : 1-3% 7-15 : 4-11% >> M>F 7-11y M=F >11 F>M Migraine with aura is seen in15 to 30 percent of children

8. Features peculiar to Childhood migraine Aura is seen in 15 to 30 percent of children Aura is preceded by mood changes or withdrawal from activity Typical auras are visual like seeing spots, flashes of light, colour, zigzag lines, distortion of images, visual scotoma. Sensory aura like pins and needles Headache usually bilateral Localisation of headache poorly reported. Duration is shorter and therefore less time available to start abortive therapy. Also making it difficult to judge response.

9. Migraine variants Migraine attack accompanied by or manifested by transient neurological symptoms Symptoms may occur just before, during or after headache. Sometimes headache may be absent or very mild. 1.Hemiplegic Migraine 2.Basilar Migraine 3.Ophthalmoplegic migraine 4.Benign paroxysmal vertigo 5.Benign paroxysmal torticollis of infancy 6.Confusional migraine 7.Alice in wonderland syndrome 8.Cyclic vomiting 9.Abdominal migraine 10.Retinal Migraine( Amaurosis Fugax)

10. Complications of Migraine Status migrainosus (> 72 h) Persistent aura without infarction Migrainous infarction Migraine-triggered seizure. Approach to Childhood headache ODP is very important 1)ACUTE HEADACHE Systemic infections like Malaria, Influenza, Dengue. Traumatic headache CNS inflammations like meningitis, encephalitis, abscess, vasculitis Dental infection, Sinusitis First episode of migraine

11. 2) ACUTE RECURRENT HEADACHES Migraine 3) CHRONIC NONPROGRESSIVE HEADACHE Tension type headache, Depression, anxiety, analgesic overuse Headache, Chronic daily headache belongs to migraine spectrum that occurs daily. Refractive error 4)CHRONIC PROGRESSIVE HEADACHE Important to rule out Intracranial space occupying lesions like Tumour, abscess, parasitic cysts

12. Warning signs include: Suspected headache in a child below 3 years. Headache that is most severe in the morning or which awakens one from sleep. It improves as day progresses. Headache that is relieved by vomiting. Hypertension and bradycardia 6 th nerve palsy, papilloedema, Mecwen sign Headache which is persistently occipital. If headache worsens with sneezing, coughing, lying down, valsalva manoeuvre Pulsating tinnitus Confusion Lack of family history of migraine Lack of response to analgesics Focal neurodeficits, localising signs.

13. IMAGING: Usually not necessary except when warning signs are present. MRI Better definition, better visualisation of posterior fossa, no radiation hazard, Gadolinium enhanced MR scan is better for vascular lesions and lesions that disrupt blood brain barrier. This is the modality of choice in suspected structural lesions. Expensive, May require sedation, Time consuming CT scan A contrast CT scan is good enough in most cases is faster and cheaper and is more readily available. It may be done where circumstances are not suggestive of intracranial pathology. A plain CT has a role only in Intracranial Haemorrhage and trauma.

14. Factors precipitating Migraine headaches Stress/ anxiety Fatigue/ exertion Sleep deprivation Glare/ Rapidly changing TV sequences Hunger Certain foods like Cheese, Chocolates, MSG, Some preservatives and additives Menstruation Drugs – oc pills, Antidepressants, vasodilators like hydralazine, NTG Travel to high altitude Hot climate Cold food Refractive error and eyestrain

15. MANAGEMENT OF PRIMARY HEADACHE DURING INTERVAL PHASE Reassurance regarding self limiting and benign nature of illnesses Organization of mealtimes, sleeptime, Studies and school Address stress in the family Avoid precipitating factors Encourage learning relaxation techniques, Yoganidra Less severe cases may be offered alternative medicine eg. acupunture, homeopathy. DURING ACUTE PHASE Dark and quiet room Relaxation Sleep medications

16. PHARMACOTHERAPY OF MIGRAINE ABORTIVE THERAPY:(Difficult to use in children) NSAIDS and other analgesics: Particularly effective in children Paracetamol, ibuprofen are widely used. May cause withdrawal or rebound headaches Ergotamine: Contraindicated below age 6 May be of use only if used during Aura or early headache. Adverse effects:Gastrointestinal upset.

17. Triptans: Sumatriptan or one of its analogs is used world over. Not licensed below 12 years but is still used off label. Tablet: 25, 50 and 100 mg. Trials proved it as good as placebo in children. Adult dose 25 to 100 mg. May be repeated in 2 hours SC injection 6mg. Ped dose 0.1mg/kg sc. May be repeated after 2 hrs. Now a nasal spray available. Parenteral preferred as nausea may interfere with oral admin. Adverse effects: dizziness, chest pain, tingling numbness. Contraindications: Uncontrolled hypertension, heart disease, basilar and hemiplegic migraine and pregnancy

18. PROPHYLACTIC THERAPY: Indication: If attacks are frequent and or severe enough to disturb scholastic activities. If attacks cause psychological disturbances. Migraine can remit during childhood but often is lifelong with exacerbations. Counselling is necessary. Therapy to be tried for 6 to 8 weeks to find improvement. Therapy to be reviewed every 10 to 12 months and tapered to check remission.

19. 1)Beta blockers: Commonly used in children. Propranolol given two to three times a day. Nadolol given once daily Adverse effects: Bradycardia, depression in adolescents Contraindications: Asthma, H/O depression, 2) Antidepressants: Amitryptiline is most often preferred in older children and adolescents. Can help control accompanying anxiety, depression. Adverse Effects: Dry mouth, postural hypotension, Sweating, Weight gain, somnolence, lethary, cramps, ventricular arrhythmias, precipitate seizure. SSRIs have also been tried and found useful.

20. 3) Antihistaminic: Flunarizine is commonly used in India. Both H1 and calcium channel blocker. 5mg daily at bedtime. Adverse: dry mouth, Somnolence, Weight gain, depression 4)Anti serotonin: Cyproheptadine successfully used for decades. No evidence supports this. Adverse effects: sedation, weight gain, appetite stimulation.

21. 5)Anticonvulsants: Valproate: May cause liver damage, lethargy and sedation, Impairment of learning, alopecia, hyperphagia, weight gain. Topiramate: sedation, Increased IOP. 6) Calcium channel blockers: Used in adults. Pediatric use is limited.

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