2. 14 y.o. female patient with a 2 year history of headaches that have been increasing in intensity and frequency for the past 4 months

3. Location: Quality: Associated “Autonomic Features: Aggravated by: Improved with: Duration: Family History:

4. Location: Hemicranial Quality: Pounding Associated “Autonomic Features: Phonophobia, Nausea, Dizziness, and scalp tenderness (no photophobia). No visual or sensory aura. Aggravated by routine physical activity, improved with rest and with sleep Duration: 2 to 8 hours Family History: Mother and maternal aunt have “stress headaches” which occur often with menses

5. Frequency: Severity: Medication: Triggers:

6. Frequency: 2 to 3 times per week on average Severity: Most headaches are described as severe with associated missed school and social functions Medication: Tylenol 500 mg: No help. Ibuprofen 400 mg partially reduces severity. 1° Care MD gave script for Vicodin 7.5/500 which puts her to sleep within one hour. No access to meds at school Triggers: Menses, stress, hot weather. Drinks one to 3 caffeinated beverages per day.

7. Vitals: HEENT: C/V: Neurological Examination:

8. Vitals: BP = 125/65, P= 90, BMI = 28 HEENT: No sinus percussion tenderness, TM’s clear, full ROM of jaw and neck C/V: RRR no murmors Neurological Examination: Visual Acuity Fundoscopic Exam EOM’s Tandem Gait Screening Exam

9. ???

10. Common Juvenile Migraine

11. CBC: ? CMP: ? ESR, CRP, ANA: ? TFT’s: ? U Tox: ? EEG: ? LP: ? CT of Brain: ? MRI of Brain: ?

12. A history consistent with migraine and a non-focal neurological exam without signs of raised ICP are all that are necessary for the diagnosis of migraine 1. Obtaining a neuroimaging study on a routine basis is not indicated in children with recurrent headaches and a normal neurologic examination (Level B; class II and class III evidence). 2. Neuroimaging should be considered in children with an abnormal neurologic examination (e.g., focal findings, signs of increased intracranial pressure, significant alteration of consciousness), the coexistence of seizures, or both (Level B; class II and class III evidence). 3. Neuroimaging should be considered in children in whom there are historical features to suggest the recent onset of severe headache, change in the type of headache, or if there are associated features that suggest neurologic dysfunction (Level B; class II and class III evidence). Neurology 2002;59:490-498

13. Acute Symptomatic Rx ? ? Daily preventative Rx

14. Acute Symptomatic Rx Right Drug Right Dose Right Timing of Administration At least 2 to 3 disabling headaches per week Headaches that are poorly responsive to optimal Acute Symptomatic Rx Daily preventative Rx

15. Acute Symptomatic Rx NSAIDS Triptans Ergotamines Aspirin/Caffeine compounds Dopamine Antagonists Tylenol Narcotics have no antimigraine properties and should be avoided whenever possible TCA’s Ca++ Channel Antagonists Anticonvulsants Cyproheptadine Propranolol, while widely perscribed is poorly tolerated and not necessarily any more effective Daily preventative Rx

16. Modifying Triggers Good Sleep Healthy Eating Regular exercise Minimize caffeine usage OCP’s for refractory catamenial migraine

17. 17 y.o. female with a 10 year history of headaches that have been daily for the past 18 months or so

18. Location: Daily time course: Migrainous features with peaks: Progressive: Remote history of common migraine:? Number of school days missed or work activities missed:?

19. Location: Holocephalic, nuchal Daily time course: Daily from awakening until sleep Migrainous features with peaks: 2-3 hour peaks with phonophobia and dizziness (no photophobia, no vomiting, moderate in intensity) Progressive: No Remote history of common migraine: Yes Number of school days missed or work activities missed: 17 days missed this year

20. Acute Symptomatic Treatment What is being used What is the dose How often administered Caffeine Usage Exercise, sleep, eating patterns Other pain symptoms Any depression or anxiety symptoms Psychosocial functioning

21. Acute Symptomatic Treatment What is being used: Migraine Excedrine What is the dose: Two tabs How often administered: Three times daily Caffeine Usage: 4 to 6 beverages daily Exercise, sleep, eating patterns: No exercise, overweight, insommnia Other pain symptoms: Multiple arthralgias. Dx’d with fibromyalgia and chronic GI pain Any depression or anxiety symptoms: Anxiety symptoms exist Psychosocial functioning: Poor grades due to absences

22. Vitals: HEENT: C/V: Neurological exam:

23. Vitals: BP = 135/78, P = 86, BMI = 42.7 HEENT: Normal C/V: RRR no murmurs Neurological exam: Non focal. No signs of raised ICP

24. Diagnosis ???

25. Diagnosis Chronic Daily Headache Transformed Migraine Headache Medication overuse Headache

26. Medication management Taper off Acute Symptomatic Treatment Taper off caffeine usage Start Daily preventative therapy PRN NSAIDs with limit one dose/day and 3 doses per week Goal of keeping the patient functional despite daily pain Importance of exercise, diet, and sleep

27. A 10 y.o. boy with a two month history of daily headaches

28. Location: Autonomic Symptoms: Time course of Headaches: Progressive: Exacerbating factors: Relieving factors: Neurological Deficits: Visual Symptoms: Constitutional Symptoms:

29. Location: Holocephalic Autonomic Symptoms: Repetitive Vomiting upon awakening, then clears. No anorexia. Time course of Headaches: Daily and progressive without pain-free intervals Progressive: Yes Exacerbating factors: Supine posture, valsalva, cough, sneeze, bending over Relieving factors: Recumbent posture, not moving head Neurological Deficits: None reported Visual Symptoms: Diplopia without visual obscurations Constitutional Symptoms: No fever, weight loss, fatigue.

30. Vitals: HEENT: C/V: Neurological Exam:

31. Vitals: BP = 120/58, P = 80, BMI = 24 HEENT: No sinus percussion tenderness, neck with full ROM, no proptosis, TM’s clear C/V: RRR without murmur Neurological Exam: MS: Alert, speech fluent/articulate, nl concentation and STM CN: VA = 20/20 OS, 20/25 OD, PEERLA, fundoscopic exam with…

33. How about this one?

34. Vitals: BP = 120/58, P = 80, BMI = 24 HEENT: No sinus percussion tenderness, neck with full ROM, no proptosis, TM’s clear C/V: RRR without murmur Neurological Exam: MS: Alert, speech fluent/articulate, nl concentation and STM CN: VA = 20/20 OS, 20/25 OD, PEERLA, fundoscopic exam with Bilateral mild-moderate papilledema, cannot fully abduct OS otherwise EOMI, face symmetric, palate and tongue midline Motor: Nl tone, strength, symmetric DTR’s, downgoing toes Sensory: Nl light touch, cold and vibration sense Coordination: No dysmetria or tremor or titubation Gait: Normal narrow-base gait. Tandem gait intact

35. ???

36. Raised Intracranial Pressure Due to… Pseudotumor Cerebri Hydrocephalus Brain Tumor Brain Abscess Venous Sinus Thrombosis

37. The Next Step?

38. Neuroimaging Urgent CT vs MRI with MR Venogram

40. The Next Step?

41. Lumbar Puncture Opening Pressure Cell Count with Cytology Protein and Glucose

42. Lumbar Puncture Opening Pressure: 380 mmH2O Cell Count with Cytology: 2 WBC (70% monocytes). No malignant cells. Protein and Glucose: Protein = 24 mg/dl, glucose 80 mg/dl (serum = 120 mg/dl)

43. Pseudotumor Cerebri Treatment ?

44. Pseudotumor Cerebri Medication Treatment Acetazolamide Other Diuretics Glucocorticosteroids Optic nerve Sheath Fenestration Ophthalmology Follow Up Visual Field Testing Headache Evaluation

45. Now get out there and treat headaches with confidence. Stop unnecessary neuroimaging. Develop a Treatment Plan! You can do it.