1. Sue Lipscombe Brighton GP Sue Lipscombe Brighton GP Children’s Headaches 0-18?

2. SINISTER and SECONDARYHEADACHES  Less than 5% of children’s headaches are serious disease or due to physical problems  Fever – common cause of headaches  Occasionally meningitis but never recurrent  Head Trauma causes pain at time and site of trauma, lingering headache is worry  Sinus infection, TMJ, Dental Problems  Tests are only necessary if sinister headache is being considered. They will not diagnose migraine or tension type headaches  Less than 5% of children’s headaches are serious disease or due to physical problems  Fever – common cause of headaches  Occasionally meningitis but never recurrent  Head Trauma causes pain at time and site of trauma, lingering headache is worry  Sinus infection, TMJ, Dental Problems  Tests are only necessary if sinister headache is being considered. They will not diagnose migraine or tension type headaches

3. CHILDREN MAY BE TOO YOUNG TO DESCRIBE THEIR HEADACHES  BUT they may draw them  Every picture tells a story  Parents may try to get child to draw headache as soon as the child feels better so it remains fresh in their mind  Your doctor may want your child to tell their own story so please try and encourage them to talk. Parents/ carers will be able to add their own helpful thoughts later.  BUT they may draw them  Every picture tells a story  Parents may try to get child to draw headache as soon as the child feels better so it remains fresh in their mind  Your doctor may want your child to tell their own story so please try and encourage them to talk. Parents/ carers will be able to add their own helpful thoughts later.

5. Parents can act as observers  Watch how the child looks  Do they look pale and ill?  Do they stop eating?  Do they carry on with activities?  Do they choose to lie down?  Do they recover rapidly?  What do they do with their hands?  Watch how the child looks  Do they look pale and ill?  Do they stop eating?  Do they carry on with activities?  Do they choose to lie down?  Do they recover rapidly?  What do they do with their hands?

6. Watch Hand Gestures

7. Headache can start young Even babies and toddlers may have headaches  6 years old (in preceding 6mth period)  16 % of children  12 years old (in preceding 6months)  19 % of children Even babies and toddlers may have headaches  6 years old (in preceding 6mth period)  16 % of children  12 years old (in preceding 6months)  19 % of children

8. Migraine can start young  Migraine grows from infrequent to frequent:  6 years old 2%  10 years old 6%  18 years old10%  Many (65 - 90%) not problematical:  infrequent, short, familiar  Migraine grows from infrequent to frequent:  6 years old 2%  10 years old 6%  18 years old10%  Many (65 - 90%) not problematical:  infrequent, short, familiar

9. Development migraine over time  Before puberty: boys = girls  After puberty: more girls  Luckily 35%: Migraine disappears 8 > 13 yrs  But: 12 % of migraine children develop severe migraine eventually > prophylactics  Duration attack increases with age  8 yrs: duration 1-2 hrs  15 yrs: duration > 2 hrs  Before puberty: boys = girls  After puberty: more girls  Luckily 35%: Migraine disappears 8 > 13 yrs  But: 12 % of migraine children develop severe migraine eventually > prophylactics  Duration attack increases with age  8 yrs: duration 1-2 hrs  15 yrs: duration > 2 hrs

10. Associated (risk)factors-1  Parents and siblings with headache  Unhappiness in the family  Low SES-status (tension-type, but no relation with migraine)  Depression (tension-type)  More motion sickness (migraine)  More abdominal (migraine)  Other pains (tension-type)  Parents and siblings with headache  Unhappiness in the family  Low SES-status (tension-type, but no relation with migraine)  Depression (tension-type)  More motion sickness (migraine)  More abdominal (migraine)  Other pains (tension-type)

11. Diagnosis migraine; differences with adults Children  Migraine in ‘family’ useful  Duration 2-72 (2-12 usually)  Often 1-2 hrs in young children  Often bilateral headache  Occipital headache rare & alarming  Sleep frequently helps Children  Migraine in ‘family’ useful  Duration 2-72 (2-12 usually)  Often 1-2 hrs in young children  Often bilateral headache  Occipital headache rare & alarming  Sleep frequently helps Adults  Family history not so helpful  Duration 4-72 (4-36 usually)  If < 2 hrs no migraine  Unilateral headache common  Occipital headache common and not alarming  Disturbs sleep

12. What to do: tension-type headache  Explanation, reassurance  “It is one of those common pains, a nuisance rather than a problem”  Recognising benign pattern with diary  Explanation, reassurance  “It is one of those common pains, a nuisance rather than a problem”  Recognising benign pattern with diary

15. What to do: tension-type headache the parents  Distraction activities: they help  Lying down not helpful (for headache…)  Keeping diaries is useful for child and parent and doctor  Distraction activities: they help  Lying down not helpful (for headache…)  Keeping diaries is useful for child and parent and doctor

16. STRESS  A MAJOR FACTOR  ONE OR TWO HEADACHES MAY CAUSE STRESS- DEVELOP CDH  EXAMINATION STRESS  PERFORMANCE STRESS  PARENTAL STRESS  RELATIONSHIP STRESSES  A MAJOR FACTOR  ONE OR TWO HEADACHES MAY CAUSE STRESS- DEVELOP CDH  EXAMINATION STRESS  PERFORMANCE STRESS  PARENTAL STRESS  RELATIONSHIP STRESSES

17. What to do: tension-type headache referrals  Training in optimal posture and excercises is more an adult thing  optional for youngsters and adolescents  ‘Therapy’ is boring and they are right  Children should play, not do fitness training  Sport is a child thing but can be dancing or other diverting exercise  Training in optimal posture and excercises is more an adult thing  optional for youngsters and adolescents  ‘Therapy’ is boring and they are right  Children should play, not do fitness training  Sport is a child thing but can be dancing or other diverting exercise

18. What to do: tension-type headache referrals  The person of the physiotherapist is more important than the therapy itself  Encourage to start a sport  Change towards more activity  Rarely medication  Though: careful manipulation is optional  The person of the physiotherapist is more important than the therapy itself  Encourage to start a sport  Change towards more activity  Rarely medication  Though: careful manipulation is optional

19. What to do: migraine the parents  Rest, quiteness, let the child alone  Lying down is very helpful  Children ‘sleep migraine out of their head’  Being a tough child is not helpful  Inform teachers, friends: same approach  Try and avoid triggers  Travel sickness is a pointer  Rest, quiteness, let the child alone  Lying down is very helpful  Children ‘sleep migraine out of their head’  Being a tough child is not helpful  Inform teachers, friends: same approach  Try and avoid triggers  Travel sickness is a pointer

21. What to do: migraine the parents  Sleep hygiene is very effective  After 6 months fewer attacks  Shorter attacks  Regulate or stop caffeine intake  Food triggers usually obvious but try groups rather than individual foods  It may make the child introspective if it isn’t obvious  Sleep hygiene is very effective  After 6 months fewer attacks  Shorter attacks  Regulate or stop caffeine intake  Food triggers usually obvious but try groups rather than individual foods  It may make the child introspective if it isn’t obvious

22. Prevention is better than cure  Try and avoid any obvious triggers  Each child is an individual and needs individual care  Parents may recognise triggers that the child misses  The child should always be part of discussion for many reasons  Try and avoid any obvious triggers  Each child is an individual and needs individual care  Parents may recognise triggers that the child misses  The child should always be part of discussion for many reasons

23. What to do: migraine medication  In time, high dosage of minor pain medication, NSAID’s, and/or anti-emetics  Similar to adults  Parents tend to under-dose a child  Often the attack is too short to treat  Triptans are allowed now from 12 yrs old: nasal spray  In time, high dosage of minor pain medication, NSAID’s, and/or anti-emetics  Similar to adults  Parents tend to under-dose a child  Often the attack is too short to treat  Triptans are allowed now from 12 yrs old: nasal spray

24. What to do: migraine medication  Prophylactics : > 3 attacks a month  Betablockers  (valproate)  Pizotifen - sanomigran  Stop after 6 – 12 months  Start again if the attack frequency recurs, but often this is unnecessary  Prophylactics : > 3 attacks a month  Betablockers  (valproate)  Pizotifen - sanomigran  Stop after 6 – 12 months  Start again if the attack frequency recurs, but often this is unnecessary

25. Behavioural problems  Are they sometimes caused by headache?

26. PARENTS  Keep diary of headache frequency  Keep diary of headache severity  Keep diary of foods  Keep diary of events  Keep diary of medication  Keep diary of stresses  Keep diary of sleep  Keep diary of headache frequency  Keep diary of headache severity  Keep diary of foods  Keep diary of events  Keep diary of medication  Keep diary of stresses  Keep diary of sleep

27. REMEMBER  Diagnosis is made by the history  Blood tests are rarely necessary  Brain scans are scary, dangerous and usually not necessary  Usually the longer the history the less likely the headache is to be sinister.  Diagnosis is made by the history  Blood tests are rarely necessary  Brain scans are scary, dangerous and usually not necessary  Usually the longer the history the less likely the headache is to be sinister.

28. The change we need to effect

29. QUESTIONS? AND THANK YOU FOR LISTENING AND WORKING WITH DOCTORS TO HELP YOUR CHILD