1. Headache for the PCP: Evaluation and Initial Management
Chris Jackman, MD
Assistant Professor of Neurology
Child Neurology of Riley Hospital
Director, Riley Headache Center

2. Objectives Identify a systemic evaluation of a headache patient
Evaluate for causes of secondary headache
Recognize how to diagnose common primary headache symptoms of childhood
Identify how to treat primary headache syndromes

3. Initial Evaluation

4. 1. Shoulder shrug and look to parents 2. “I don’t know” 3. “Headaches

5. It’s in the history Time course Pain description Associated symptoms
Location
Severity
Quality
Associated symptoms

6. Other questions: Pain description Associated symptoms Location
Severity
Quality
Associated symptoms
Aura
Nausea, vomiting
Photophobia, phonophobia
Light-headedness, vertigo
Autonomic features

7. Red Flags Time course Location Postural Focal neurologic signs
Progressive
Morning
Location
Posterior
Postural
Focal neurologic signs
Any
Systemic signs
Fevers, rash
Family history
As in, none
Age
Under 6 years

8. Physical exam
Eyes / Fundus
TMJ
Face
Muscles
Skin
Neurologic

9. Secondary Headaches

10. Non-neurologic causes of secondary headaches
Dental/ TMJ
Allergies/ congestion
Sinus inflammation/ infection
Ear infection/ Mastoiditis
Hypothyroidism
Pheochromocytoma (Hypertension)
Eye-strain

11. It is (probably) not a tumor
Brain tumors are very rare
BUT…
You only need to miss one to be incompetent
The chance of finding a tumor in a patient with headaches and a normal neurological exam is…

12. It is not a tumor Very low, but not quite zero
Brain tumors typically cause headache when they cause increased pressure
A much more common presentation is focal neurologic signs with minor headache

13. It is a tumor Key features Time course (Progressive)
Timing (On awakening)
Postural (Supine)
Focal Neurologic signs
Seizures

14. If it’s not a tumor, what is it?

15. Intracerbral Hemorrhage
Features
Time course (Acute)
History of trauma
Focal Neurologic signs
Types of hemorrhage
Subdural
Epidural
Subarachnoid
Paranchymal
Interventricular

16. Venous sinus thrombosis
Associated with primary or secondary hypercoagulable state
Present with signs of increased intracranial pressure
Sometimes hemorrhage
Red Flags
Time course (Progressive or static)
Postural
Neurologic signs
Papilledema
6th nerve palsies

17. Ideopathic intracranial hypertension
Mechanism unknown
More female, more obese
Headache with visual loss
Red Flags
Time course (Progressive or static)
Postural
Neurologic signs
Papilledema
6th nerve palsies

18. Ideopathic intracranial hypotension
Seen in some connective tissue diseases from dural ectasia (or ideopathic)
Mimics LP headache
Red Flags
Time course (Progressive or static)
Postural

19. Meningitis / Encephallitis
Red flags:
Systemic signs (fever)
Focal Neurologic signs (meningismus, encephalopathy, seizures)

20. Chiari I Malformation
Protrusion of cerebellar tonsils below the foramen of Monro
Red flags:
Location (posterior)
Postural, pain with
neck movements
Focal Neurologic signs
(ataxia)
Worse with cough,
sneezing, valsalva

21. Post-traumatic or Post-concussive Headache
Red flags: See hemorrhage
Will get better, may take months
Cognitive changes are common, will also improve

22. Headache Evaluation

23. Do I order LABS?

24. Study of 104 children referred to Child Neurology
Headaches in children younger than seven years of age Chu ML, Shinnar S. Arch Neurol, 49:1992; 79-82
Study of 104 children referred to Child Neurology
Studies performed prior by the pediatrician
Studies included:
Cell counts
Basic electrolytes
Tranaminases
Urinalysis
“Uniformly unrevealing”
Similar prospective study in adults of 193 patients showed same results

25. Do I order a SCAN?

26. American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches 2002
Neuroimaging
Combined 6 studies
605 of 1275 had imaging (CT in 116, MRI in 483, both in 75)
97 children with imaging abnormalities (16%)
79 considered incidental
14 surgically treatable
4 medically treatable

27. American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches 2002
Of the 14 surgical lesions:
10 tumors
3 symptomatic vascular malfomations
1 significant arachnoid cyst
All had an abnormal neurologic examination
Papilledema
Abnormal eye movements
Motor dysfunction
Gait dysfunction

28. American Academy of Neurology Practice Parameter: Evaluation of children and adolescents with recurrent headaches 2002
Parameters which distinguish headache patients with space occupying lesions
Headache of less than one month duration
Absence of a family history of migraine
Abnormal neurological examination
Gait abnormalities
Seizures
Those patients with headaches for less than 6 months and at least one of the above symptoms are considered “high-risk”
“High-risk” = 4% chance of space occupying lesion

29. CT vs. MRI?

30. Primary Headache Disorders

31. 48% had previously received a physician diagnosis
Migraine Diagnosis and Treatment: Results From the American Migraine Study II Headache 2001;41:
Survey mailed to 20,000 homes, identified 3577 individuals who met criteria for migraine
48% had previously received a physician diagnosis
24% of those undiagnosed had missed at least one day of work or school in the previous three months
Those missed were:
Lower income
Younger age (18-29)
Male

32. Migraine epidemiology
Headache prevalence
Tension type HA 78%
Migraine 16%
Children
3-8% by age 3
37-52% by age 7
57-82% in 7-15 year olds
Peak incidence
Women – age (aura), (without)
Men – age 5 (aura), (without)
Comprehensive Review of Headache Medicine; Levin M Ed; Oxford 2008

33. “If nothing is wrong with me, doctor, why do I have these headaches?”

34. Migraine pathophysiology
Primarily a NEUROGENIC process
We think
For now

35. Migraine pathophysiology
Aura
Cortical spreading depression
Front of profound depolarization
Moves across cortex ~ 3mm/min
Following by suppression of neural activity lasting minutes
A.P. Leão.

36. Cortical Spreading Depression

37. Migraine pathophysiology

38. Migraine without aura Pediatric diagnostic criteria
At least five attacks fulfilling criteria B-D (below)
Headache attacks lasting 1 to 72 h
Headache having at least two of the following characteristics:
Unilateral location, may be bilateral, frontotemporal (not occipital)
Pulsing quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity (eg, walking, climbing stairs)
During the headache, at least one of the following:
Nausea or vomiting
Photophobia and phonophobia, which may be inferred from behavior
Not attributed to another disorder

39. Migraine with aura Pediatric diagnostic criteria
At least two attacks fulfilling the criteria B-D (below)
Aura consisting of at least one of the following, but no motor weakness:
Fully reversible visual symptoms, including positive features or negative features (e.g., flickering lights, spots, or lines)
Fully reversible sensory symptoms, including positive features (i.e., pins and needles) or negative features (ie, numbness)
Fully reversible dysphasic speech disturbances
At least two of the following:
Homonymous visual symptoms or unilateral sensory symptoms
At least one aura symptom develops gradually over 5 min or different aura symptoms occur in succession over 5 min
Each symptom lasts between 5 min and 60 min
Not attributable to another disorder

40. And…

41. …Chronic Daily Headache…

42. Chronic Daily Headache
Transformed (or chronic) migraine
History of migraine
Progresses to chronic, low level headache with periodic migraines
Chronic tension type headache
Lack significant migranous features
Less severe intensity
Tightening more than pulsating
New daily persistent headache

43. Chronic daily headaches - evaluation
Look for red flags*
Ask about analgesic overuse
* Especially in New Daily Persistent Headache

44. Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents
D. Lewis, MD; S. Ashwal, MD; A. Hershey, MD; D. Hirtz, MD; M. Yonker, MD; and S. Silberstein, MD
NEUROLOGY 2004; 63: 2215–2224

45. Migraine treatment - Abortive
Ibuprofen, acetaminophen, ketorolac, indomethacin, ASA
Combinations (Acetaminophen/ASA/caffeine)
Antiemetics (promethazine, chlorpromethazine
Opiates, barbituates (no, no, never…)
Corticosteroids
Triptans
5HT1b, 1d, and 1f agonists
Contraindications include cardiovascular disease or risk factors, Reynaud’s, hemiplegic migraine
Side effects include nausea, dizziness, chest and throat tightness

47. Migraine treatment - Abortive

48. Migraine treatment - Prophylactic
When to use prophylaxis
Headaches frequent
Headaches severe
Headaches disruptive
Side effects and burden of taking a daily medicine < the life disruption caused by (appropriately treated) headaches

49. Migraine treatment - Prophylactic
Antihistamines
Beta-blockers
Tricyclics
Anticonvulsants
Calcium channel blockers

50. Migraine treatment - Prophylactic
Antihistamines
Cyproheptadine
Little studied, often used
Reduce headaches from 8.4 to 3.7 per month
Somnolence, weight gain
Initial dose 1-2 mg QHS, max 4 mg BID
Lewis D, Diamond S, Scott D, et al. Prophylactic treatment of pediatric
migraine. Headache 2004;44:230–237.

51. Migraine treatment - Prophylactic
Beta-blockers
Propranolol most studied
Three small, prospective class II studies with conflicting results
Exercise intolerance
Contraindicated in asthma, depression
Initial dose 20 mg, up to 160 mg

52. Migraine treatment - Prophylactic
Tricyclics
Amitriptyline most studied
Anticholinergic effects, somnolence
Black box warning re: suicidality
Baseline EKG and monitor for QT prolongation
Initial dose 10 mg up to 100 mg
Give at dinner

53. Migraine treatment - Prophylactic
Anticonvulsants
Topiramate (or zonisamide)
Best studied
Valproate
Effective but side effects can be significant
Levetiracetam/ Lamotrigine
Limited (poor) data

54. Migraine treatment - Prophylactic
Calcium channel blockers
Conflicting data
Familial hemiplegic migraine
Abdominal discomfort
Monitor EKG and blood pressure

55. Chronic Daily Headache - Treatment
Preventative medications –
Evidence is spotty at best
Topiramate is best studied, anecdotally all migraine medications may work
Transformed migraine or for medication overuse – early prophylactic treatment
Chronic tension type headache – late medical treatment
New daily persistent headache – doesn’t matter

56. Non-pharmacologic Treatment
Lifestyle! Lifestyle! Lifestyle!
Analgesic overuse
Sleep
Diet
Psychiatric

57. Non-pharmacologic Treatment
Analgesic overuse
Opiotes/ barbiturates > triptans >>NSAIDS
Any used over 15 days/month, some over 10 days/month
Can treat by a period of elimination or by moderation
Headaches may take 4-6 weeks to improve

58. Non-pharmacologic Treatment
Sleep
Snoring
Movements
Quality
Quantity
Continuity

59. Non-pharmacologic Treatment
Diet
Meats (Iron, B12)
Vegetables (Folate?)
Skipping meals
Hydration
Caffeine

60. Non-pharmacologic Treatment
Psychiatric evaluation
Anxiety
Depression
Obsessive-compulsive disorder
Non-pharmocologic management
Biofeedback
Self-hypnosis
Relaxation

61. Take home points: Red flags
Progressive time course
Postural
Worse in the morning
Any neurologic sign or symptom
Worse with valsalva
Practice your fundoscopic and cranial nerve exam

62. Closing thoughts… Watch for red flags Know when to image
If unsure whether to image, refer
Know helpful lifestyle modifications
Know when to start or refer for prophylactic medications
Remember: “Your patient does not want to have a headache”

63. References
Sargent JD, Solbach P. Medical evaluation of migraineurs: review of the value of laboratory and radiologic tests; Headache 1983; 23:62-65
Chu ML, Shinnar S. Headaches in children younger than seven years of age Arch Neurol, 49; 1992; pp79-82
Maytal J, Robert S. Bienkowski, Patel M and Eviatar L. The Value of Brain Imaging in Children With Headaches. Pediatrics 1995;96;
Levin M Ed; Comprehensive Review of Headache Medicine: Oxford 2008
Lewis D, Ashwal, S; Hershey A; Hirtz D; Yonker, M; and Silberstein S, Practice Parameter: Pharmacological Treatment of migraine headache in children and adolescents. Neurology 2004;63:2215–2224
Ludvigsson J. Propranolol used in prophylaxis of migraine in children. Acta Neurol 1974;50:109–115.
Forsythe WI, Gillies D, Sills MA. Propranolol (Inderal) in the treatment of childhood migraine. Dev Med Child Neurol 1984;26:737–741.
Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis and propranolol in the treatment of juvenile classic migraine. Pediatrics 1987;79:593–597.
D.W. Lewis, MD; S. Ashwal, MD; G. Dahl, BS; D. Dorbad, MD; D. Hirtz. Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002;59:490–498