1. Childhood headaches §Dr Adi Aran §Neuropediatric Unit §SZMC

2. Childhood Headaches §-Occur in approx. 35% of children by 7 years of age and 50% of children by 15. §Frequent headache occure in approx. 2.5 % of children by 7 years of age and 15% of children by 15. §-Parents are looking for reassurance that the headache is not due to a serious cause

3. Where the pain coming from? §Not - the brain, most of the meninges overlying the brain and the bony skull §Pain referred to the head can arise from: l Extra/Intra-cranial arteries and veins l Cranial or spinal nerves l Basal meninges l Cranial or cervical muscles l Extracranial structures (sinuses, teeth, etc.)

4. Pathogenesis of pain- cont. §Cranial circ. & supratentorial structures exhibit pain via the trigeminal nerve §Posterior fossa structures exhibit pain via the first three cranial nerves, the vagus nerve and the glossopharyngeal nerve

5. Categorize the Headache §Acute §Acute recurrent §Chronic non-progressive §Chronic progressive §Mixed time severity time severity time severity time severity time severity

6. An Isolated, Acute Headache §Causes: l Viral illness l Sinusitis l Migraine l Dental abscess l Intracranial hemorrhage w/ or w/o trauma l Hypertension l Meningitis  All of the children with serious underline condition had one or more objective finding on neurological examination

7. Other common Headaches §Migraine Headache (Acute recurrent) §Stress-Related (Tension) Headache (Chronic non progressive) §Headache Due to Increased ICP (Chronic progressive) §Cluster Headache (Acute recurrent) §Migraine superimposed on Stress-Related (Tension) Headache (mixed)

8. As Usual-Take a Good History §Characteristics of a typical episode l Location l Intensity of pain l Duration l Frequency l Preceding aura? l Associated symptoms (GI, visual, neuro)

9. Other Good Questions §What makes the headache better or worse? §When do the headaches occur? §Any known triggers or stressors? l School, lack of sleep, problems in the family §Any medications? §Any pertinent family history? l Allergies, migraines

10. A Focused Physical Exam §Growth Parameters §Blood Pressure §Head Circumference §Head and neck palpation §Fundoscopic Exam §Complete Neurologic Examination §Skin §More than 98% of children with brain tumors have objective neurologic findings

11. Neuroimaging – pros and cons §Pros – some times it is the only thing that will assist the parents (and the doctor) to sleep at night. §Cons – it is not cost- effective - the vast majority of children in Israel will undergo CT scan. - The estimates of lifetime attributable risk for fatal cancer from one current generation CT scan range from 1 per 2000 scans for young infants to 1 per 5000for those 10 years old. - Low doses of inoising radiation in infancy may adversely affect cognitive abilities

12. Indications For A Scan §Any neurologic abnormality §Signs of increased intracranial pressure l Papilledema l HA’s or vomiting at night or awakening. l Pain is worsened with sneezing, coughing, etc. l Chronic progressive pattern §Worst headache of life §Presence of neurocutaneus syndrome §Presence of V-P shunt §Age younger than three years §Unvarying location of headaches

13. Is an LP indiciated? §After brain imaging l Herniation is bad! §If pseudotumor cerebri is suspected l Elevated opening pressure l Partial relief in HA

14. Migraines in Childhood §Most common cause of intermittent HA’s in childhood §The prevalence in children under 7 years old is higher in boys and after 11 years is higher in girls. §Diagnosis is based on classical symptoms

15. Criteria for Diagnosis of pediatric migraine without aura (ICHD, IHS – 2004) A. Five or more attacks fulfilling features B-D. B. Headache attack lasting 1 to 72 hours. C. Episodes are accompanied by at least one of the following: l Photophobia and phonophobia l Abdominal pain, nausea or vomiting D. Episodes characterized by at least two of the following: l Bilateral or unilateral ( frontal / temporal) location l pulsatile pain l Moderate to severe intensity l Aggravated by routine physical activities Not a criteria: l Complete relief after rest l Family history of migraines

16. Potential Migraine Triggers §Emotional or Physiological Stress l Missing a meal, lack of sleep §Environmental Factors §Foods and Chemicals l Caffeine, chocolate, cheese, aspartame, etc. §Drugs l Histamine-2 blockers, OCP’s, Ritalin.....

17. Migraine with Aura (Classic) §Precedes the HA onset and lasts 5-20 minutes §What’s an aura? l Flashing or colored lights, dots, zigzags l Scotomas l Distortions of size

18. Complicated Migraine §Migraine associated with a transient neurologic abnormality l Hemiparesis, visual field defects, CN palsy Most common cause of CN-III palsy in children l “Basilar” migraine Vertigo, ataxia, tinnitus, etc. More common in adolescent females

19. Migraine Equivalent Episodes §Episodes that do not necessarily include headache, but believed to be of a migrainous etiology l Confusional migraine l Benign paroxysmal vertigo l Alice in Wonderland Syndrome l Abdominal migraine

20. Stress-Related Headache §Also known as a tension headache §Pain is characteristically: l A “band-like” distribution l Generally, a constant ache w/ some throbbing l Usually constant §More common in older girls

21. Similar to Common Migraine §Stress-Related l More related to fatigue, but do not readily respond to sleep l Minimal nausea l Usually involve the whole head §Common Migraine l Respond to sleeping l Nausea and vomiting are characteristic l Usually unilateral

22. Increased Intracranial Pressure §Expanding lesion may cause progressive worsening of headaches l Direct expansion l Obstruction of CSF flow §Headache is worse at night or immediately after waking

23. Other Cues That ICP is Elevated §Headache is worsened by maneuvers which raise venous pressure l Bending over, coughing, straining §Transient obscurations of vision §Vomiting may provide temporary relief

24. Look for Papilledema §It may not be seen in every instance of elevated ICP. §If seen, a Head CT or MRI is indicated prior to attempting an LP Fig 19-105 from Zitelli: Atlas of Pediatric Physical Diagnosis, St. Louis, 1997, Mosby-Wolfe

25. Causes of increased ICP §Neoplasm l Mass-effect l Resulting in obstructive hydrocephalus §Hydrocephalus l Independent of or resulting from neoplasm §Pseudotumor cerebri §Subdural hemorrhage

26. Brain Tumors in Children §Etiology of headache §Headaches occur in 60-65% of patients w/ brain tumors §Symptoms are: l Worse on waking l May improve with vomiting Contemporary Pediatrics, 16:11 November 1999, p86.

27. Cluster Headaches §Occurs rarely during adolescence l Recurrent, extreme, non-throbbing pain l Usually around an eye l Eye watering l Facial Flushing

28. Other Headaches to Consider §Refractive errors l Related to reading or working at a computer l Providing eye rest improves symptom §Ictal or postictal phenomenon l Poorly-controlled seizure d/o l Head-grabbing in a developmentally delayed patient?

29. Management and Therapy for Recurrent Headaches

30. Patient and Family Education §Reassurance that the etiology is benign §Explain the diagnosis and underlying cause §Help the patient recognize situations that precipitate and exacerbate headaches

31. Acute Migraine Management §Sleep-effective in most attacks l Sedatives may be helpful §Simple analgesics l Less efficacious once an attack is established l Neurophen is more effective than Acamol / Optalgin §Sumatriptan (Imitrex) §Cafergot / Temigran (DHE) §Migralev

32. Sumatriptan (Imitrex) §A selective 5-HT agonist ( Relert, Naramig, Rizalt ) §Effective, but expensive l Dosage recommendations in children have not been fully established §Comes in a variety of preparations l PO, Intranasal

33. Prophylaxis Against Migraines §Identification of precipitating factors and subsequently avoiding them l Food diary, family dynamics, school problems §Pharmacologic Therapy §Behavioral therapy l Biofeedback l Relaxation therapy l Hypnosis

34. One Form of Relaxation Therapy

35. Another Form of Relaxation Therapy

36. When to Use Pharmacotherapy §When the frequency of headaches interferes with the child’s daily functioning l Missing school l Nutritional concerns §Most regimens are based on adult practice or anecdotal reports

37. Prophylactic Agents §Propranolol (deralin) –1-4 mg/kg divided TID §Clonirit –25 mcg x 2/d §Amitryptiline (Elavil) –Can be used for children 6 or older §Topamax

38. Tension Headache Treatment §Acute attacks l Simple analgesia, rest, and removal of stressors is very effective §Chronic occurrence l Identification of stressful situations l Relaxation techniques, massage therapy and acupuncture

39. “Analgesic” Abuse Headache §AKA “Drug-induced Refractory” headache §A consequence of frequent analgesic use l Do not occur only with opiates l Ergotamine, NSAIDS and acetaminophen have also been cited as being causative §Treatment- Educating the patient and family on how to alter pattern of analgesic use

40. A Little Review on Headaches §Take a thorough history §Categorize the headache §Perform a physical exam l Any neurological abnormality or papilledema? §Head Imaging? LP? §Acute Treatment §Prophylaxis/Avoidance