1. Headaches

2. CONTINUITY CLINIC Objectives Recognize and differentiate the elements of history and physical findings associated with the following headache types: Recognize and differentiate the elements of history and physical findings associated with the following headache types: Migraine Migraine Tension headache Tension headache Increased Intracranial Pressure Increased Intracranial Pressure Know which signs and symptoms mandate imaging Know which signs and symptoms mandate imaging Be familiar with the treatment options for HA Be familiar with the treatment options for HA

3. CONTINUITY CLINIC Background Recurrent headache is a common complaint in pediatric clinics; studies indicate that it affects: almost 40% of kids by 7 years of age 75% of children by 15years of age. Important causes: Migraine Psychogenic factors Increased intracranial pressure Depression may present as headache Toxins (carbon monoxide) Sinusitis Eye issues: refractive errors,strabismus Bruxism.

4. Migraines

5. CONTINUITY CLINIC Migraines Migraine headaches are the most common cause of intermittent headache in children. Migraine headaches are the most common cause of intermittent headache in children. They are defined as a recurrent headache with symptom-free intervals and at least three of the following (Prensky criteria): They are defined as a recurrent headache with symptom-free intervals and at least three of the following (Prensky criteria): Hemi cranial pain Hemi cranial pain Throbbing/pulsatile character of pain Throbbing/pulsatile character of pain Associated with abdominal pain, nausea, OR vomiting Associated with abdominal pain, nausea, OR vomiting Relieved by rest/sleep Relieved by rest/sleep Visual, sensory or motor aura Visual, sensory or motor aura Family history in first-degree relative Family history in first-degree relative

6. CONTINUITY CLINIC History Location of pain – usually bifrontal or temporal regions Location of pain – usually bifrontal or temporal regions Photophobia, phonophobia or lightheadedness Photophobia, phonophobia or lightheadedness Limitation of daily activities? – often nausea and vomiting cause the greatest limitation Limitation of daily activities? – often nausea and vomiting cause the greatest limitation School School Sports Sports How long? - often last 1-3 hours (longest is up to 24 hours) How long? - often last 1-3 hours (longest is up to 24 hours) Focal neurologic symptoms? – before, during, or after Focal neurologic symptoms? – before, during, or after Visual disturbances Visual disturbances Weakness Weakness Paresthesia Paresthesia Precipitating causes including: Precipitating causes including: Emotional stress Emotional stress Changes in sleep patterns Changes in sleep patterns Menstruation Menstruation Weather changes Weather changes Foods - chocolate, cola, nuts, MSG and meats Foods - chocolate, cola, nuts, MSG and meats Relief from analgesics Relief from analgesics Family history is very important: an estimated 80-90% of children with migraine have an affected relative. Family history is very important: an estimated 80-90% of children with migraine have an affected relative.

7. CONTINUITY CLINIC Classification of Migraines Migraine with aura begins with an aura, usually visual, that lasts 5-20 minutes prior to the headache. Visual phenomenon may include photopsia (flashing lights), fortification spectra (zigzags), black dots, colored lights, scotomata, or distortions of size. It may be the only manifestation of the headache, and children are often distressed by this symptom and have difficulty describing it. Migraine without aura is usually diagnosed with the help of family history and the character of the headache. Complicated migraine is migraine associated with a transient, focal neurologic abnormality, most commonly hemiparesis, hemianesthesia, visual field deficits and cranial nerve palsies (oculomotor). It is the most common cause of third cranial nerve palsy in children. Note that because of these associated deficits, evaluation of the first episode should include a CT or MRI brain scan.

8. CONTINUITY CLINIC Treatment For an acute episode, sleep is very effective in curing the pain. Non-prescription analgesics such as acetaminophen, ibuprofen or naproxen are usually effective. Others may require combinations of metaclopramide plus analgesics. Note that once an attack begins, the effectiveness of oral agents is reduced by decreased gastric motility and absorption. Ergotamines (dihydroergotamine mesylate) have long been effective in the treatment of severe migraine. Sumatriptan, subcutaneously, has been proven effective in children, but the oral forms have been much less successful, and it is an expensive drug. Deal with precipitating factors! Stress management techniques are important, as difficulty dealing with stress is the most common precipitating factor. Biofeedback and relaxation techniques have demonstrated efficacy in several studies, and should be a part of the treatment regimen. Prophylaxis is appropriate when the headaches interfere with the child’s ability participate in school or activities. Some neurologists would consider prophylaxis reasonable when children suffer more than two incapacitating headaches per month or those who have recurrent complicated migraine. Medications used for prophylaxis include amitryptiline, propranolol and cyproheptadine.

9. CONTINUITY CLINIC Medication Review Metoclopramide - enhances GI motility and is an effective antinauseant Metoclopramide - enhances GI motility and is an effective antinauseant Ergotamines - administered to relieve migraine headaches; the drug is roughly 70% effective in controlling acute migraine attacks Sumatriptan - very specific for one subtype of serotonin receptors. It is approved for the treatment of migraine with or without aura, but not for long-term migraine prophylaxis or for the management of hemiplegic or basilar migraine. Although the efficacy of subcutaneous sumatriptan as an abortive agent in the treatment of migraine has been demonstrated, headache recurrence is a frequent problem.

10. Tension Headaches

11. CONTINUITY CLINIC Tension Headache - History Chronic stress or tension-type headaches are not very common in the pediatric population before puberty and represent a diagnosis of exclusion. Chronic stress or tension-type headaches are not very common in the pediatric population before puberty and represent a diagnosis of exclusion. These headaches are characterized by a diffuse, symmetric distribution in the frontal or occipital areas, often described as bandlike. These headaches are characterized by a diffuse, symmetric distribution in the frontal or occipital areas, often described as bandlike. The pain may be described as constant and aching, as opposed to the throbbing of migraine The pain may be described as constant and aching, as opposed to the throbbing of migraine HA is usually accompanied by fatigue but not the nausea and vomiting of migraine or increased intracranial pressure. HA is usually accompanied by fatigue but not the nausea and vomiting of migraine or increased intracranial pressure. Activities are usually not limited, although most occur during the school day and may be related to activities such as tests. Activities are usually not limited, although most occur during the school day and may be related to activities such as tests. It is important to give the child the opportunity to share concerns and conflicts, as most can provide insight into the cause of the headache. One must also screen for depression by asking about changes in mood, behavior, appetite, sleep and withdrawl. It is important to give the child the opportunity to share concerns and conflicts, as most can provide insight into the cause of the headache. One must also screen for depression by asking about changes in mood, behavior, appetite, sleep and withdrawl.

12. CONTINUITY CLINIC Tension Headache - Treatment Education about how stress can cause headaches leads to a discussion about how to reduce anxiety or remove anxiety- producing situations Biofeedback and self-relaxation techniques have a significant role in symptom management, and are most effective for a chronic headache Analgesics such as acetaminophen and ibuprofen usually provide relief for acute headache

13. Increased Intracranial Pressure

14. CONTINUITY CLINIC Increased ICP - History Headache initially sporadic and occurs in the early hours of the morning; it may also awaken the child. Pain is diffuse and generalized, usually in frontal or occipital regions. It is exacerbated by movements that increase ICP (coughing, sneezing, straining and lying flat) and may be temporarily relieved by vomiting. As ICP increases, the child may become more irritable or lethargic Physical exam with special attention to the neurologic exam Cranial nerve abnormalities Defects in visual fields or acuity Changes in DTR or muscle strength Fundoscopic exam may reveal papilledema or retinal hemorrhage Check the pupillary exam for asymmetry of the light reflexes. Cranial bruit on exam may represent an arteriovenous malformation, especially when asymmetric or eliminated by compression of the ipsilateral carotid artery. Other important components of the physical include growth parameters (chronic illness, hypothalamopituitary dysfunction), head circumference, blood pressure and skin (trauma or neurocutaneous disorder).

15. CONTINUITY CLINIC NORMAL FUNDOSCOPIC EXAMINATION PAPILLOEDEMA RETINAL HEMORRHAGES

16. CONTINUITY CLINIC Light Reflex

17. WARNING Cushing’s Triad (hypertension, bradycardia and irregular respirations) is a late finding! Absence of these symptoms does not eliminate the possibility of increased ICP.

18. CONTINUITY CLINIC Increased ICP The most common causes of elevated ICP in children include hydrocephalus, brain tumors (esp. posterior fossa), subdural hematoma, cerebral abscess, meningitis/encephalitis, pseudotumor cerebri and chronic lead poisoning. If elevated ICP is suspected, it is implicit that imaging is done before lumbar puncture.

19. Imaging

20. CONTINUITY CLINIC When to order? Abnormal neurologic signs on physical exam Acute increased frequency or severity of headache; overall change in pattern Focal neurologic signs/symptoms during HA (complicated migraine) Recent school failure, behavior change, fall-off in linear growth rate HA awakens child during sleep, occurs in early morning with increasing frequency or severity Brief cough HA in child or adolescent Visual graying out occurs at the peak of HA instead of at the aura Cluster HA in a child; any child less than 5 years whose primary complaint is HA Focal neuro signs/symptoms develop during the aura with fixed laterality or occur at the peak of HA instead of during the aura

21. CONTINUITY CLINIC