1. Headaches Jonathan Rochlin, MD January 9, 2008

2. 2 Outline  Epidemiology  Pathophysiology  Differential Diagnosis and Work-Up  Algorithmic Approach  A Closer Look at Migraine Headaches

3. 3 Outline  Epidemiology  Pathophysiology  Differential Diagnosis and Work-Up  Algorithmic Approach  A Closer Look at Migraine Headaches

4. 4 Epidemiology  Headaches are common complaints  Most headaches are cared for at home  Headaches are usually one in a number of complaints  Headache as a chief complaint: 1% of patients

5. 5 Outline  Epidemiology  Pathophysiology  Differential Diagnosis and Work-Up  Algorithmic Approach  A Closer Look at Migraine Headaches

6. 6 Pathophysiology of Pain Sensation  Extracranial structures: all sensitive to pain  Intracranial structures: some sensitive, some not Insensitive to pain: brain, ependymal lining, choroid plexus, dura mater, arachnoid, pia mater Sensitive to pain: proximal portions of cerebral arteries, venous sinuses and the cerebral veins  Attempting to locate the anatomic site of the pain source is difficult

7. 7 Pathophysiologic Classification  Vascular Headaches: Due to Vasodilation Include Headaches Due To:  Migraines  Hypertension  Hypoxia  Fever  Muscle Contraction Headaches: Tension

8. 8 Pathophysiologic Classification  Headaches Due To Inflammation: Intracranial Infections:  Bacterial Meningitis  Encephalitis  Orbital Cellulitis  Cerebral Abscess Extracranial Infections:  Strep Throat  AOM/Otitis Externa  Sinus Infections  Dental Infections

9. 9 Pathophysiologic Classification  Headaches Due To Compression/Traction: Brain Tumor Intracranial Hemorrhage Pseudotumor Cerebri Hydrocephalus Post-LP Headache

10. 10 Pathophysiologic Classification  Headaches Due To Other Causes: Psychogenic Headaches Ocular Headaches

11. 11 Outline  Epidemiology  Pathophysiology  Differential Diagnosis and Work-Up  Algorithmic Approach  A Closer Look at Migraine Headaches

12. 12 Another Word About Epidemiology  Causes of headache in the pediatric emergency department: Viral Illness39.2% Sinusitis16.0% Migraine15.6% Post-traumatic Headache6.6% Strep Throat4.9% Tension Headache4.5% Total of benign causes86.8%  Burton LJ et al. “Headache etiology in a pediatric emergency department.” Pediatric Emergency Care 1997. Feb; 13 (1): 1-4.

13. 13 Differentiating the Benign From the Bad  History  Physical Exam  Laboratory and Radiology Testing

14. 14 History  Temporal Pattern: Acute:  Localized: –Dental Infections –Sinus Infections –Otitis Media/Externa –Post-Traumatic –First Migraine

15. 15 History  Temporal Pattern: Acute:  Generalized: –Intracranial Hemorrhage –Hypertension –Hypoxia –Systemic Infections: »Bacterial Meningitis »Encephalitis »Febrile Illnesses –First Migraine

16. 16 History  Temporal Pattern: Acute and Recurrent:  Migraine Headaches  Tension Headaches

17. 17 History  Temporal Pattern: Chronic But Non-Progressive:  Tension Headaches  Psychogenic Headaches  Medication Overuse Headaches Chronic And Progressive:  Brain Tumor  Cerebral Abscess  Hydrocephalus  Intracranial Hemorrhage  Pseudotumor Cerebri

18. 18 History  Characteristic Historical Findings of Brain Tumor Headaches in Children: Headaches that wake the patient up Headaches that are present when waking up in the morning Headaches that worsen over time (chronic and progressive) Headaches associated with vomiting Behavioral changes Polydipsia/polyuria (craniopharyngioma) History of neurologic deficits Honig PJ, Charney EB. “Children with brain tumor headaches: distinguishing features.” American J Dis Child 1982. 136: 121-141.

19. 19 History  Other Historical Findings Worrisome For Intracranial Pathology: Headache worsened by cough, urination or defecation Headache < 6 months duration Pulsatile tinnitus “Worst headache”/thunderclap headache Growth abnormalities PMedHx risk factors for intracranial pathology:  VP Shunt  Neurocutaneous syndromes  Coagulopathic patients  Sickle cell patients Absence of family history of migraines

20. 20 History  Other Key Points To Address: Fever Mental Status Changes Past Medical History Family History Trauma Environmental Exposure Headaches Worse With Bending Over Visual Changes

21. 21 Physical Exam  General Appearance  Vital Signs: Temperature BP O 2 Sats

22. 22 Physical Exam  Head and Neck Exam: Signs of Trauma Otitis Media/Externa Strep Throat Teeth and Gingiva TMJ and Masseter Muscles Nuchal Rigidity Sinus Tenderness Head Circumference Muscle Tenderness

23. 23 Physical Exam – The Skin

24. 24 Physical Exam – The Skin

25. 25 Physical Exam – The Skin

26. 26 Physical Exam – The Skin

27. 27 Physical Exam – The Skin

28. 28 Physical Exam – The Skin

29. 29 Physical Exam – The Skin

30. 30 Physical Exam – The Skin

31. 31 Physical Exam – The Skin

32. 32 Physical Exam – The Skin

33. 33 Physical Exam  The Neurologic Exam: Funduscopic Examination Extraocular Muscle Movement Pupillary Light Reflex Other Cranial Nerves Gait Motor Examination

34. 34 Studies  CT  LP  Bloodwork  Most Patients Do Not Need Any of These Based on Lewis DW et al. “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.

35. 35 CT Evaluation of Headaches  1 fatal cancer for every 1,000 CTs performed Rice HE et al. “Review of radiation risks from computed tomography: essentials for the pediatric surgeon.” J Pediatric Surgery 2007. Apr; 42(4): 603-7.

36. 36 CT Evaluation of Headaches  Each year, 500 children will ultimately die from cancer due to CT scans Brenner D et al. “Estimated risks of radiation-induced fatal cancer from pediatric CT.” American J Roentgenol 2001. Feb; 176(2): 289-96.

37. 37 CT Evaluation of Headaches

38. 38 CT Evaluation of Headaches  Who Should Get a CT: Points on the History Concerning For Intracranial Pathology:  Headaches that wake the patient up  Headaches that are present when waking up in the morning  Headaches that worsen over time (chronic and progressive)  Headaches associated with vomiting  Behavioral changes  Polydipsia/polyuria (craniopharyngioma)  History of neurologic deficits

39. 39 CT Evaluation of Headaches  Who Should Get a CT: Points on the History Concerning For Intracranial Pathology:  Headache worsened by cough, urination or defecation  Headache < 6 months duration  Pulsatile tinnitus  “Worst headache”/thunderclap headache  Growth abnormalities  PMedHx risk factors for intracranial pathology: –VP Shunt –Neurocutaneous syndromes –Coagulopathic patients –Sickle cell patients  Absence of family history of migraines  Altered mental status

40. 40 CT Evaluation of Headaches  Who Should Get a CT: Points on the Physical Exam Concerning For Intracranial Pathology:  Abnormal Neurologic Exam  Abnormal Skin Findings Suggestive of Neurocutaneous Disorder  Macrocephaly

41. 41 CT Evaluation of Headaches  Who Does NOT Need a CT: Most Patients With Migraines Those With Chronic But Non-Progressing Headaches

42. 42 MRI Evaluation of Headache  Usually this is not practical in the ED  For some lesions, MRI is better  However, do not delay the CT in order to get an MRI later

43. 43 LP for Evaluation of Headache  Who Should Get an LP: Suspected Meningitis/Encephalitis Suspected Pseudotumor Cerebri Suspected Subarachnoid Hemorrhage  With Abnormal Neurologic Exam, Do a CT First

44. 44 Bloodwork for Evaluation of Headache  Rarely Indicated  Exceptions Include: Serious Infectious Process (Meningitis Or Encephalitis):  CBCD  BCx Elevated BP:  BMP  UA

45. 45 Outline  Epidemiology  Pathophysiology  Differential Diagnosis and Work-Up  Algorithmic Approach  A Closer Look at Migraine Headaches

46. 46 Algorithm History of acute and recurrent headaches Yes No Typical pattern with no new findings Yes No Migraine Tension Abnormal neuro exam or Hx/PE findings concerning for intracranial pathology Yes No Go to CT scan algorithm No Yes Fever Other abnormalities on Hx/PE Yes No Increased BP Hypertensive headache * Hypoxic Hypoxic headache History of trauma Post- traumatic headache CO poisoning Exposure Focal tenderness Sinusitis Dental infection TMJ dysfunction Tension headache Go to fever algorithm Migraine Tension Psychogenic Med Overuse

47. 47 Fever Algorithm Patient has fever Meningeal signs Yes No Viral syndrome Sinusitis Dental infection Otitis Media/Externa Strep Throat LP * LP abnormal Yes No Bacterial meningitis Encephalitis Consider CT to rule out bleed or tumor

48. 48 CT Scan Algorithm Patient has abnormal neuro exam or Hx/PE findings concerning for intracranial pathology CT scan CT scan abnormal Yes No Brain tumor Intracranial bleed Hydrocephalus Cerebral abscess Orbital cellulitis Malfunctioning VP shunt * Extremely severe headache or stiff neck YesNo LP with opening pressure Pleocytosis Yes No Increased RBCsIncreased WBCs Bacterial meningitis Encephalitis Subarachnoid hemorrhage Elevated opening pressure Yes No Pseudotumor cerebri Pseudopapilledema Neuro findings abnormal for >60 minutes Yes No Migraine Stroke Todd’s paralysis (after unwitnessed seizure)

49. 49 Outline  Epidemiology  Pathophysiology  Differential Diagnosis and Work-Up  Algorithmic Approach  A Closer Look at Migraine Headaches

50. 50 Migraine Diagnosis  International Headache Society Criteria: A. At least 5 attacks fulfilling B - D B. Headache lasts 1 - 72 hours C. Headache with at least 2 of following:  Bilateral or unilateral (but not occipital)  Pulsating  Moderate to severe pain intensity  Aggravated by or causing avoidance of routine physical activity (walking, climbing stairs) D. At least 1 of the following during headache:  Nausea and/or vomiting  Photophobia and phonophobia (can infer)

51. 51 Migraine Diagnosis  Often Positive Family History  Aura in 15-40% of Patients  Characteristic Pattern

52. 52 Tension Headaches  Characteristics of Tension Headaches: Duration 30 minutes - 7 days No aura 2 out of 4 of following:  Pressing, tightening, band-like, dull  Nonpulsatile  Mild or moderate  Bilateral, often frontal  Not aggravated by physical activity Both of following:  No nausea or vomiting  Photophobia or phonophobia (but not both)

53. 53 Migraine Treatment  Ask: What Usually Works  Goal: Break the Headache Quickly  First-Line Treatment: No Emesis:  Ibuprofen PO: –10mg/kg q6hrs; max=800mg/dose  Acetaminophen PO: –15mg/kg q4hrs; max=1,000mg/dose  Naproxen PO: –5-7mg/kg q8hrs; max=1,250mg/day  Some evidence that ibuprofen is better than acetaminophen

54. 54 Migraine Treatment  First-Line Treatment: Emesis:  Pain Medications: –Acetaminophen PR: »15mg/kg q4hrs; max=1,000mg/dose –Toradol IV: »0.5mg/kg q6hrs; max=30mg  Antiemetics: –Phenergan PR/IM/IV: »1mg/kg/dose q4-6hrs; max=25mg »Only for children >2 years old –Consider Reglan/Zofran/Compazine  IV Hydration

55. 55 Migraine Treatment  Second-Line Treatment: Triptans:  5HT1 Receptor Agonists  Promote Vasoconstriction  Sumatriptan (Imitrex)

56. 56 Migraine Treatment  Intranasal Sumatriptan (Imitrex): Does Not Work If Under 6 Years Old Dosage:  6-12 Years Old: –5mg –If This Is Not Effective, Try 10mg in 2 Hours  > 12 Years Old: –20mg –If This Is Not Effective, Try Again in 2 Hours  Do Not Give More Than Twice/24hrs Usually There is Some Effect Within 30 Minutes This Has a Bad/Salty Taste

57. 57 Migraine Treatment  Third-Line Treatment: Ergotamines Contraindications:  Pregnancy  Use of Triptans Within 24hrs Dihydroergotamine (DHE):  Alpha-Adrenergic Blocker  Vasoconstrictor  Dosage: –0.5mg IV or 1mg SQ –Only in Children > 10 Years Old

58. 58 Migraine Treatment  Attempt to Induce Sleep Place in a Quiet and Dark Room  Avoid Precipitating Factors  Avoid Opioids

59. 59 Key Points  Most Headaches Have Benign Causes  Remember The Uncommon But Serious Causes  Address The Temporal Pattern  Always Get Temperature and BP Readings  Do a Complete Neurologic Exam, Including Fundi  Only Patients With Abnormal Neurologic Exams or Findings Suggestive of Intracranial Pathology Need a CT

60. 60 References  BEIR V (Committee on the Biological Effects of Ionizing Radiations). Health effects of exposure to low levels of ionizing radiation. Washington, DC: National Academy Press, 1990.  Brazis PW, Lee AG. “Approach to the child with headache.” www.uptodate.com.  Brenner D et al. “Estimated risks of radiation-induced fatal cancer from pediatric CT.” American J Roentgenol 2001. Feb; 176(2): 289-96.  Burton LJ et al. “Headache etiology in a pediatric emergency department.” Pediatric Emergency Care 1997. Feb; 13 (1): 1-4.  Burton LJ et al. “Headache in the Pediatric Patient.” The Clinical Practice of Emergency Medicine, 5 th Edition. Draft.  Cruse RP. “Classification of migraine in children.” www.uptodate.com.  Cruse RP. “Management of migraine headache in children.” www.uptodate.com. www.uptodate.com  Cruise RP. “Tension headache in children.” www.uptodate.com.  Honig PJ, Charney EB. “Children with brain tumor headaches: distinguishing features.” American J Dis Child 1982. 136: 121-141.  International Commission on Radiological Protection. 1990 recommendations of the International Commission on Radiological Protection. Oxford, England: Pergamon, 1991. ICRP publication 60.

61. 61 References  King C. “Emergent evaluation of headache in children.” www.uptodate.com.  King C. “Headache.” Textbook of Pediatric Emergency Medicine, 5 th edition. Fleisher GR et al Editors. Lippincott Williams & Wilkins: Philadelphia. 2006. 511-518.  Lewis DW et al. “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.  Lewis D et al. “Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology 2004. 63: 2215-2224.  Olsen J. “The International Classification of Headache Disorders.” Cephalagia 2004. 24; Suppl 1: 23-44.  Rice HE et al. “Review of radiation risks from computed tomography: essentials for the pediatric surgeon.” J Pediatric Surgery 2007. Apr; 42(4): 603-7.

62. 62 The End