UC Combined Conference
Headache August 11, 2010
Brad Sobolewski, MD Cincinnati Children’s Hospital Medical Center
Today we will discuss…
The evaluation and workup of headaches
in the Pediatric ED
When you should be worried about bad
causes for headaches (tumors)
When to get a CT scan
How to treat migraines
Struggling to stay awake? Follow along and answer the
five high impact questions on the handout
Etymology
The basics
Our job is to make the distinction between “bad” and benign headaches
History and physical help us diagnose most headaches
Brain tumors are rare, and will (almost always) have associated history and exam findings
Background
Common causes of headaches in the ED
Headaches associated with viral infection
and fever
Due to vasodilation from increased blood flow
Sinusitis
Migraine
Post traumatic headache
Tension headache
Rare causes of headaches that we worry about
Brain tumors
Intracranial hemorrhage
Hydrocephalus
Pseudotumor cerebri
A common occurrence
75% will have had a headache by age 15
Most are treated at home
Stats from a Pediatric Neurologist at CCHMC
Of the headaches referred to the ED…
Serious neurological diagnosis (6%)
Meningitis, shunt malfunction, hydrocephalus,
metastatic tumor
All had an abnormal neuro exam
Most common etiology - Viral infections with fever
Migraine (20%)
Pathophysiology
Extracranial structures directly sense pain
Sinuses, ears, scalp, muscles
The brain and its lining does not
Intracranial vessels can sense pain
The location of pathology may not directly
correlate with location of pain
Headache from “eye strain” is rare in
children
Differential diagnosis
Muscle Contraction Tension headache
Inflammation Infectious causes
(meningitis, sinusitis)
TMJ
Traction/Compression Intracranial hemorrhage
Tumors
Pseudotumor cerebri
Hydrocephalus
Persistent CSF leak after LP
Psychogenic
Vascular Fever
Migraines
Hypertension - vessel dilation and increased ICP
Hypoxia - causes cerebral vasodilation
CO poisoning, near drowning
Chronic disease exacerbation (CF, cyanotic heart disease)
History and
Physical Exam
Take a good history
Is the onset is sudden or gradual?
Abrupt onset + severe pain could be a ruptured AVM
Location?
Severity?
Unreliable in young children
Has this happened before?
Frequency and duration?
Constant (for days) yet can go to sleep - tension or psychogenic cause
Take a good history
Associated symptoms?
Visual or motor symptoms – migraine with
aura
Fever and mental status changes -
encephalitis
After trauma?
Have you tried any therapies?
Has it caused you to miss school or work?
Take a good history
Past medical history
CF and cyanotic heart disease – hypoxia
Renal disease – hypertension
Family history
“Migraine” may be used to describe any manner of chronic headaches
Environmental factors
Abrupt onset of headache and nausea in several family members? Think CO poisoning
Take a good history
Think about the following if the headache…
Awakens from sleep or upon awakening each morning – brain tumor
Starts later in the day – tension, migraine
Is worse when bending over – sinusitis
In an overweight (female) adolescent with newly impaired vision - pseudotumor cerebri
Physical exam
Vital signs - Get an
accurate BP!
Pro Tip: Abnormal
neuro exam
findings in children
with headaches
are rare
Physical exam - HEENT
Macrocephaly Hydrocephalus
Scalp Hematoma in unwitnessed trauma (abuse or
otherwise)
Auscultation through fontanelle could reveal the bruit of an AVM
Eyes Assess visual acuity and visual fields
Sluggish pupil – mass effect
Impaired EOM – orbital infection
Look at the fundi for papilledema
Physical exam - HEENT
Ears Otitis media/externa
Mastoiditis (exam findings)
Facial tenderness and erythema – maxillary and frontal sinusitis
Teeth – dental abscess
Pharynx – pharyngitis
Neck Nuchal rigidity – meningitis, ICH, tumor
Won’t/can’t look up – RPA
Assess the site of a VP shunt
Physical exam - Skin
What diseases are these skin lesions associated with?
Café au lait spots
Neurofibromatosis
Ash leaf spots
Tuberous sclerosis
Physical exam - Neuro
New focal findings are bad Some migraine patients have ophthalmoplegia,
extremity numbness – but this is not new
Mental status Depressed? Elevated ICP, bleed, mass
Cranial nerve abnormalities ICP, direct nerve compression
Sensory and motor function
Gait
Age appropriate fine motor coordination
Workup and
Evaluation
Workup
Labs
Appropriate if you are considering a severe systemic illness or infection
Lumbar puncture
If you suspect a mass lesion or a bleed CT first
If CT is negative in a suspected subarachnoid bleed
In pseudotumor cerebri get an opening pressure
Imaging
Xrays are useless – unless doing a shunt series
CT
For ICH, hydrocephalus, edema, herniation
Not high rez for masses, especially posterior fossa
To CT or not to CT…
Who should you scan? (Medina, 1997 and Lewis, 2007)
Persistent H/A and duration <6 months that hasn’t
responded to medical treatment
Abnormal neurologic findings (especially papilledema,
nystagmus, gait/motor abnormalities, seizures)
Severe, acute, and no FHx of migraines
Persistent H/A with substantial episodes of confusion,
disorientation, or emesis
Awakens from sleep or occurs immediately on awakening
FHx or PMHx of disorders that may predispose to CNS
lesions
Signs of elevated ICP
What about MRIs?
Great resolution for masses
Less available in all institutions at all hours
Requires patients to be still
Do you want to sedate a child with an abnormal neuro exam?
Generally can be done within 24-28h as outpatient
Summary of headache red flags
Sudden onset or onset during exertion
Abnormal neuro exam
Seizure
Worsening under observation
Abnormal vital signs (fever, Cushing’s VS)
First/worst (severe) headache
New onset headaches in patient with cancer, immunodeficiency
Fever?
Meningeal signs
Elevated BP
Abnormal neuro exam
Transient motor disturbance +/- prodrome
+/- relieved by sleep
Brain tumor
ICH
pseudotumor
Hypertension
Meningitis
Viral encephalitis
Other neurologic deficit
Brain abscess
Viral syndrome
Sinusitis
Dental abscess
Systemic illness
Migraine
Trauma
Posttraumatic headache
Stress +/- other somatic
complaints +/- depression
Tension/psychogenic headache
Fever?
Meningeal signs
Elevated BP
Abnormal neuro exam
Transient motor disturbance +/- prodrome
+/- relieved by sleep
Brain tumor
ICH
pseudotumor
Hypertension
Meningitis
Viral encephalitis
Other neurologic deficit
Brain abscess
Viral syndrome
Sinusitis
Dental abscess
Systemic illness
Migraine
Trauma
Posttraumatic headache
Stress +/- other somatic
complaints +/- depression
Tension/psychogenic headache
Illustrative Cases
Case #1
A 14 year old male has fever to 101oF, headache and neck stiffness
No history of trauma
Neuro exam is normal
He has pain with neck flexion
He had diarrhea two days ago, and “just feels tired”
Viral meningitis
A little bit about viral meningitis
Enterovirus is responsible for 90%
Older children have fever, headaches (usually retro-orbital or frontal), and photophobia
More than 50% of patients older than 1-2 years old have nuchal rigidity
Do we do an LP in suspected viral meningitis in a well appearing patient with a normal neuro exam?
The CSF features of viral meningitis and bacterial meningitis overlap
Definitely tap if Ill-appearing or signs of encephalitis
Case #2
A 7 year old male has a two month history of headaches upon awakening in the morning
He also has morning vomiting
The symptoms are getting worse
The neuro exam is normal
Historical findings in patients with brain tumors
Nocturnal headache/pain when arising in the AM
Worsening over time
Associated with progressively worsening
vomiting
Note: migraines can make you puke too
Behavioral changes
Polydipsia/polyuria (craniopharyngioma)
Probable neurologic deficits
Ataxia, clumsiness, blurred vision, diplopia
Honig PJ, Charney EB. Children with brain tumor headaches: distinguishing features.
Am J Dis Child 1982; 136: 121-141.
What if you suspect a brain tumor?
First, order a CT…
If negative and…
No signs of elevated ICP
Normal neuro exam
You can D/C home provided that they can get
evaluated and get MRI within 24-48h
Tell parents to bring kid back to ED for…
Clinical deterioration
Mental status changes
Vomiting
Case #3
A 15 year old female with no previous history of headaches presents with a pounding frontal headache and nausea
Prior to the headache she had left arm weakness and tingling that lasted for 30 minutes
Her mom thinks that she’s having a stroke like their dead grandma
Migraine pathophysiology
Due to a hyperexcitable cerebral cortex
Pain is due to extracranial vascular dilation
Calcium channel activation
Plasma proteins leak from dilated vessels leading to
sterile inflammation
Intracranial vasoconstriction also has a role
Trigeminal pain fibers are hyperexcitable too
Other external stimuli can worsen pain sensation
(allodynia)
Migraine headaches
Two main types
Migraine with aura
Migraine without aura
Also…
Acute migraine
Status migrainosus
Migraine variants
Migraine precursors
Migraine without aura
A simple mnemonic to help remember the common symptoms of migraine without aura
Photophobia
Unilateral
Nausea
Throbbing
Diagnosis of migraine without aura
A. At least five attacks fulfilling criteria B-D (below)
B. Headache attacks lasting 1 to 72 h
C. Headache having at least two of the following characteristics:
Unilateral location, may be bilateral, frontotemporal (not occipital)
Pulsing quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity (eg, walking, climbing stairs)
D. During the headache, at least one of the following:
Nausea or vomiting
Photophobia and phonophobia, which may be inferred from behavior
E. Not attributed to another disorder
Migraine with aura
Common aura symptoms
Visual disturbances
Hemiparesis
Aphasia
The aura – transient, focal somatosensory
phenomena
Due to regionalized depolarization and
hypoperfusion
Migraine with aura
Visual disturbances (15-30%)
Occur before, or as the
headache starts
Scotoma 77%
Distortion or hallucinations
16%
Monocular visual
impairment 7%
Hachinski VC, Porchawka J, Steele JC. Visual symptoms in the migraine
syndrome. Neurol. 1973;23 :570 –579
Diagnosis of migraine with aura
A. At least two attacks fulfilling the criteria B-D (below)
B. Aura consisting of at least one of the following, but no motor weakness:
Fully reversible visual symptoms, including positive features or negative features (eg, flickering lights, spots, or lines)
Fully reversible sensory symptoms, including positive features (ie, pins and needles) or negative features (ie, numbness)
Fully reversible dysphasic speech disturbances
C. At least two of the following:
Homonymous visual symptoms or unilateral sensory symptoms
At least one aura symptom develops gradually over 5 min or different aura symptoms occur in succession over 5 min
Each symptom lasts 5 min and 60 min
D. Not attributable to another disorder
Other migraine variants
Basilar migraine 3-19% childhood migraines
Average age = 7
Dizziness, vertigo, visual disturbances, diplopia, or ataxia, followed by an occipital headache
Familial hemiplegic migraine Autosomal dominant inheritance
Transient hemiplegia precedes headache by 30-60 minutes
Headache can be contralateral to focal deficits
Postconcussion migraine Can be acute or subacute
Occurs with and without aura
Treatment is similar to conventional migraines
Migraine precursor syndromes
Cyclic vomiting syndrome Recurrent stereotypical episodic attacks of nausea
and vomiting
Symptoms resolve completely between attacks
Occur every 2-4 weeks and last 1-2 days
Treated with Cyproheptadine, amytriptylene, depakote, propranolol, or verapamil
Abdominal migraines School age children with episodic, vague, midline or
periumbilical abdominal pain
Last for hours
Do we manage migraine with aura and variants differently?
If the migraine with aura or migraine variant is hard to differentiate from a stroke – then work it up as such and consult Neuro early
No imaging if…
The history is typical ,
The aura is purely visual and <60 minutes
Neuro will get an outpatient MRI
Image to rule out stroke in the ED if…
The aura is atypical (motor or sensory)
The aura lasts >60 minutes
History of headache is new (<6 months)
If the migraine with aura is recurrent and closely matches previous symptoms then a big workup isn’t necessary
Outpatient abortive therapy…
What have they already taken at home?
Outpatient abortive therapy…
Does it work?
Ibuprofen (Lewis, 2000) is superior to placebo at 2
hours with decreased recurrence rate
Can it backfire?
Yes! Beware analgesic withdrawal headache
Gradual increase in medications leads to chronic
headache
Can occur with migraine
Low dose daily use may be worse than high dose
Treatment is stopping meds/caffeine
Preventative options
ED migraine treatment goals
Make the symptoms go away
Restore function
Align patient for outpatient follow up
Discharge instructions
Avoid triggers
Get good sleep, exercise, moderate caffeine intake, stay hydrated
Caution against analgesic overuse headache
IV management in the ED
Analgesics
Ketorolac 0.5 mg/kg IV or IM (max 30mg)
Antiemetics that also have analgesic properties
Prochlorperazine (Compazine) 0.1-0.15 mg/kg IV
(max 10mg)
Metoclopramide (Reglan) 0.5-2 mg/kg IV (max 20mg)
Also give the patient some IV fluids
Typically a 20ml/kg NS bolus over 1 hour
IV management in the ED
Side effects/things to watch out for
Ketorolac – make sure you’re not concerned
about a bleed, and that females aren’t
pregnant
Prochlorperazine – can cause restlessness,
agitation, and in rare instances a dystonic
reaction - treat with benadryl
Metoclopramide – can also cause
extrapyramidal reactions
Is Compazine safe and effective?
Prochlorperazine in Children
(Kabbouche, 2001)
The effectiveness and
tolerability of prochloroperazine
in aborting intractable migraine
in children
At 1 hour: 75 % improvement
with 50% headache free
At 3 hours: 95% improvement
with 60% Headache free
Compazine versus Toradol
Prochlorperazine versus ketorolac (Brousseau,
2004)
Double blinded RCT
At 1 hour
84.8% response to prochloroperazine
55.2% response to Ketorolac
93% response when treatments were combined
30% recurrence in 24 hours
Compazine versus Reglan
IV prochlorperazine
versus metoclopramide
(Coppola, 1996)
Double blinded RCT
with placebo
Pain improvement
10mg Compazine 82%
10mg Reglan 46%
Placebo 29%
Compazine versus Reglan (take 2)
Friedman, 2008 – A new RCT of
prochlorperazine versus metoclopramide (at a
higher dose)
Double blind RCT comparing the two agents
Both given with benadryl
Metoclopramide at 20mg (higher dose)
Primary outcome, decreased pain at 1 hour
Pain scores favored prochlorperazine –
though not statistically significant
What if they still have a headache?
If the patient is refractory to Compazine or Reglan +/- Toradol…
(Valproate) Depakote 15-20 mg/kg IV (max of 1 gram) over 10 minutes
You can try a 2nd IV dose within 3 hours of the 1st
If it works they should take the first oral dose within
four hours
Start them on 20mg/kg PO divided bid for 2 weeks
Depakote safety and efficacy
Depakote in migraines is generally well tolerated
(Reiter, 2005)
A retrospective review of 31 adolescents
40% had pain reduction
Potential adverse effects (# pts. in study)
Cold sensation (1)
Dizziness (3)
Nausea (1)
Possible absence seizure (1)
Paresthesia (2)
Tachycardia (2)
Depakote versus Compazine
Prochlorperazine 10mg vs Valproate
500mg (Tanen, 2003)
Randomized prospective double blind study
Valproate less effective in reducing pain and
nausea (p<0.001)
79% of Valproate group needed rescue
medicine
25% of the prochloroperazine group needed
rescue
What about steroids?
Does adding Dexamethasone to standard therapy decrease recurrence? (Singh, 2008)
Meta-analysis of seven trials (742 patients)
Dexamethasone added to standard antimigraine therapy reduces the rate of patients with moderate or severe headache on 24 to 72 hour follow-up
RR = 0.87 (95% CI = 0.80 to 0.95;
ARR = 9.7%
Not studied in pediatric populations
Migraine treatment summary
If you’re going to pick one agent go with Compazine
If you’re going to use two then add Toradol
Reglan is a good alternative, especially if the patient had side effects to Compazine that Benadryl didn’t help
If the first line doesn’t work, then try Depakote
Refer migraine with aura patients to the Neurology headache clinic
If Depakote doesn’t work admit
Admission for migraines
Intractable to ED therapy
Status migrainosus
Chronic severe headache
Analgesic rebound headache
Inpatient options at CCHMC
DHE (5HT1 agonist, synthetic ergot)
Valproate sodium
Magnesium
IV Steroids
What would you do?
Recall that this case was the 15 year old female with pounding frontal headache and nausea that was preceded by transient (<30min) upper extremity weakness and tingling
What do you tell her?
What is your treatment plan?
Does she need any imaging?
A few words about psychogenic headaches
Common features
School avoidance
Malingering with secondary gain
Conversion disorder
History of chronic headaches unresponsive to
various therapies
They come to the ED to “get another opinion”
Don’t dismiss them, allay parents’ fears, and arrange
for appropriate follow up
Not applicable to the acute headache!
The big 5
Take home points about headaches in the pediatric ED
Order a head CT if…
Persistent/duration <6 months and unresponsive to treatment
Abnormal neurologic findings
Awakens from sleep or immediately upon awakening
Signs of elevated ICP
Think brain tumor in patients with AM headaches, worsening
vomiting, abnormal neuro exam
Compazine or Reglan +/- Toradol and IV fluids are the best
treatments for migraines in the ED
Depakote is effective in refractory migraines
It’s hard to tell a migraine with aura from stroke if it is a
new/different headache with aura symptoms lasting >60 minutes
References
Brousseau, D. Treatment of pediatric migraine headaches: A randomized, double-blind trial of prochlorperazine versus ketorolac. Annals of Emergency Medicine, 2004. Volume 43, Issue 2, Pages 256-262.
Coppola, M. Randomized, Placebo-Controlled Evaluation of Prochlorperazine Versus Metoclopramide for Emergency Department Treatment of Migraine Headache. Annals of Emergency Medicine, 1995, Volume 26, Issue 5, Pages 541-546.
Fleisher et al. Textbook of Pediatric Emergency Medicine 5th Ed. 2006 Lippincott Williams & Wilkins.
Friedman BW, Esses D, Solorzano C, et al. A Randomized Controlled Trial of Prochlorperazine Versus Metoclopramide for Treatment of Acute Migraine Ann Emerg Med. 2008;52:399-406
Hachinski VC, Porchawka J, Steele JC. Visual symptoms in the migraine syndrome. Neurol. 1973;23 :570 –579.
Honig PJ, Charney EB. Children with brain tumor headaches: distinguishing features. Am J Dis Child 1982; 136: 121-141.
References
Kabbouche, MA, et al. Tolerability and Effectiveness of Prochlorperazine for Intractable Migraine in Children. PEDIATRICS Vol. 107 No. 4 April 2001, p. e62.
Lewis, DW, Pediatric Migraine. Pediatrics in Review. 2007;28:43-53.
Medina LS, et al. Children with headache: clinical predictors of surgical space-occupying lesions and the role of neuroimaging. Radiology 1997 Mar;202(3):819-24.
Reiter PD, Nickisch J, Merritt G. Efficacy and Tolerability of Intravenous Valproic Acid in Acute Adolescent Migraine. Headache 2005;45:899-903.
Singh, A et al. Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta-analysis and Systematic Review of the Literature. Academic Emergency Medicine. 2008. Volume 15 Issue 12, Pages 1223 - 1233.
Tanen, D. Intravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: A prospective, randomized, double-blind trial. Annals of Emergency Medicine, 2003. Volume 41, Issue 6 , Pages 847-853.
Thanks
Marielle Kabbouche, MD
Selena Hariharan, MD