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

Childhood headaches

Dr Adi AranNeuropediatric UnitSZMC

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

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: Extra/Intra-cranial arteries and veins Cranial or spinal nerves Basal meninges Cranial or cervical muscles Extracranial structures (sinuses, teeth, etc.)

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

Categorize the Headache Acute

Acute recurrent

Chronic non-progressive

Chronic progressive

Mixed

time

severity

time

severity

time

severity

time

severity

time

severity

An Isolated, Acute Headache

Causes: Viral illness Sinusitis Migraine Dental abscess Intracranial hemorrhage w/ or w/o

trauma Hypertension Meningitis

All of the children with serious underline condition had one or more objective finding on neurological examination

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)

As Usual-Take a Good History

Characteristics of a typical episode Location Intensity of pain Duration Frequency Preceding aura? Associated symptoms (GI, visual, neuro)

Other Good Questions

What makes the headache better or worse?When do the headaches occur?Any known triggers or stressors?

School, lack of sleep, problems in the family

Any medications?Any pertinent family history?

Allergies, migraines

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

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

Indications For A Scan

Any neurologic abnormalitySigns of increased intracranial pressure

Papilledema HA’s or vomiting at night or awakening. Pain is worsened with sneezing, coughing, etc. 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

Is an LP indiciated?

After brain imaging Herniation is bad!

If pseudotumor cerebri is suspected

Elevated opening pressure

Partial relief in HA

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

0%

1%

2%

3%

4%

5%

6%

Migraineincidence

Age 7Age 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:

Photophobia and phonophobia Abdominal pain, nausea or vomiting

D. Episodes characterized by at least two of the following: Bilateral or unilateral ( frontal / temporal) location pulsatile pain Moderate to severe intensity Aggravated by routine physical activitiesNot a criteria: Complete relief after rest Family history of migraines

Potential Migraine Triggers

Emotional or Physiological Stress Missing a meal, lack of sleep

Environmental FactorsFoods and Chemicals

Caffeine, chocolate, cheese, aspartame, etc.

Drugs Histamine-2 blockers, OCP’s, Ritalin.....

Migraine with Aura (Classic)

Precedes the HA onset and lasts 5-20 minutes

What’s an aura? Flashing or colored

lights, dots, zigzags Scotomas Distortions of size

Complicated Migraine

Migraine associated with a transient neurologic abnormality Hemiparesis, visual field defects, CN palsy

• Most common cause of CN-III palsy in children “Basilar” migraine

• Vertigo, ataxia, tinnitus, etc.

• More common in adolescent females

Migraine Equivalent Episodes

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

Stress-Related Headache

Also known as a tension headachePain is characteristically:

A “band-like” distribution Generally, a constant ache w/ some throbbing Usually constant

More common in older girls

Similar to Common Migraine

Stress-Related More related to fatigue,

but do not readily respond to sleep

Minimal nausea Usually involve the

whole head

Common Migraine Respond to sleeping Nausea and vomiting

are characteristic Usually unilateral

Increased Intracranial Pressure

Expanding lesion may cause progressive worsening of headaches Direct expansion Obstruction of CSF flow

Headache is worse at night or immediately after waking

Other Cues That ICP is Elevated

Headache is worsened by maneuvers which raise venous pressure Bending over, coughing, straining

Transient obscurations of vision

Vomiting may provide temporary relief

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

Causes of increased ICP

Neoplasm Mass-effect Resulting in obstructive hydrocephalus

Hydrocephalus Independent of or resulting from neoplasm

Pseudotumor cerebriSubdural hemorrhage

Brain Tumors in Children

Etiology of headacheHeadaches occur in

60-65% of patients w/ brain tumors

Symptoms are: Worse on waking May improve with

vomiting

Contemporary Pediatrics, 16:11 November 1999, p86.

Cluster Headaches

0

20

40

60

80

100

Male Female

Occurs rarely during adolescence

Recurrent, extreme, non-throbbing pain

Usually around an eye Eye watering Facial Flushing

Other Headaches to Consider

Refractive errors Related to reading or working at a computer Providing eye rest improves symptom

Ictal or postictal phenomenon Poorly-controlled seizure d/o Head-grabbing in a developmentally delayed

patient?

Management and Therapy for Recurrent Headaches

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

Acute Migraine Management

Sleep-effective in most attacks Sedatives may be helpful

Simple analgesics Less efficacious once an attack is established Neurophen is more effective than Acamol / Optalgin

Sumatriptan (Imitrex)Cafergot / Temigran (DHE)Migralev

Sumatriptan (Imitrex)

A selective 5-HT agonist

(Relert, Naramig, Rizalt)Effective, but expensive

Dosage recommendations in children have not been fully established

Comes in a variety of preparations PO, Intranasal

Prophylaxis Against Migraines

Identification of precipitating factors and subsequently avoiding them Food diary, family dynamics, school problems

Pharmacologic TherapyBehavioral therapy

Biofeedback Relaxation therapy Hypnosis

One Form of Relaxation Therapy

Another Form of Relaxation Therapy

When to Use Pharmacotherapy

When the frequency of headaches interferes with the child’s daily functioning Missing school Nutritional concerns

Most regimens are based on adult practice or anecdotal reports

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

Tension Headache Treatment

Acute attacks Simple analgesia, rest, and removal of stressors

is very effective

Chronic occurrence Identification of stressful situations Relaxation techniques, massage therapy and

acupuncture

“Analgesic” Abuse Headache

AKA “Drug-induced Refractory” headacheA consequence of frequent analgesic use

Do not occur only with opiates 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

A Little Review on Headaches

Take a thorough historyCategorize the headache Perform a physical exam

Any neurological abnormality or papilledema?

Head Imaging? LP?Acute TreatmentProphylaxis/Avoidance