This document provides an overview of pediatric and adult headaches. It begins by classifying headaches as acute, subacute, or chronic. For pediatric headaches, it outlines the important aspects of history taking and danger signs that warrant further evaluation. It describes migraine headaches in children in detail. For adult headaches, it discusses mechanisms, classification, precipitating factors, and characteristics. It provides guidance on evaluation, management, and when to refer or admit patients with headaches.

1. HEADACHE
DEPARTMENT OF FAMILY MEDICINE
POST GRADUATE INTERNS 2016:
PROCIANOS, GELEEN ANNE
RODRIGUEZ, JISA
GEMORA, KATRINA

2. OBJECTIVES:
• To classify headache according to:
– Acute
– Subacute
– Chronic
• To identify the precipitating factors, prodomal
symptoms, and its location and characteristics
• To identify pediatric and adult headache and
their managements

3. Reference:
- Clinical Neurology 6th
edition , Greenberg,
David et al.
- Nelson Textbook of Pediatrics 19th
Edition,
Kliegman, Robert et al.

4. HEADACHE:
PEDIATRIC

5. History Taking in Children:
• Location
• Character
• Triggering factors
• Relieving factors
• Time and duration
• Nausea, vomiting
• Aura, prodromal period
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

6. Danger Signals in Children:
• Progressive headache
• Sudden onset of severe headache,
unrelieved by rest or analgesics
• Headache precipitated or aggravated by
exertion, coughing or straining
• Presence of fever, seizures or neurologic
deficits
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

7. Danger Signals in Children:
• Occur in early morning then quickly
improve
• Exacerbated by Valsalva maneuver
• Presence of signs of ICP
• Any change in gait, behavior, personality
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

8. Indications for Neuroimaging Studies:
• History is not compatible with a known
headache disorder
• Points in the history are consistent with a
serious pathology
• Any focal finding in the history or neurologic
exam
• Any abnormality in the neuro exam
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

9. MIGRAINE
• Episodic headache
• Intensity: moderate or severe
• Location: focal
• Quality: throbbing
• Associated with: nausea, vomiting, light
sensitivity, sound sensitivity and aura
(typical or atypical)
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

10. CLASSIFICATION AND CLINICAL
MANIFESTATIONS: MIGRAINE W/O AURA
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

11. CLASSIFICATION AND CLINICAL
MANIFESTATIONS: MIGRAINE W/ AURA
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

12. Stages in Migraine with Aura
I. Aura: lasts for 15 to 30 minutes
II. Headache Phase: nausea, vomiting,
photophobia, phonophobia
III.Post Headache: area on the side of the
attack remains tender patient may feel
exhausted
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

13. Migraine Variants
• Cyclic Vomiting
- recurrent monthly bouts of vomiting
• Acute Confusional State
- confusion,hyperactivity, disorientation,
unresponsiveness, memory disturbances,
vomiting and lethargy
• Benign Paroxysmal Vertigo
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

14. Complicated Migraine
• Basilar Artery Migraine
– vertigo, tinnitus, diplopia, blurred vision, ataxia
and an occipital headache
– alterations in consciousness and generalized
seizures may result
• Ophthalmoplegic Migraine
– a third nerve palsy ipsilateral to the headache
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

15. Complicated Migraine
• AmaurosisFugax
– transient monocular blindness
• Hemiplegic Migraine
– unilateral sensory or motor signs during the
headache
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

16. Management of Migraine
Non-pharmacologic
• - Reassurance
• - Elimination of trigger factors
• - Modification of stress
• - Regular diet
• - Sufficient sleep
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

17. Management of Migraine
Pharmacologic
- Analgesics
- Antiemetics
(prophylactic)
- Beta blockers
- Calcium channel blockers
- Tricyclicantidrepressants
Reference: Nelson’s Textbook of Pediatrics, 19th
edition

18. HEADACHE:
ADULT

19. Mechanism of Headache
• Traction
• Inflammation
• Vascular Spasm
• Distention

20. Classification
• Primary – Migraine, Cluster, Tension; 90% of
headaches
• Secondary – associated with underlying
organic lesion or systemic illnesses; 10%

21. Classification
ACUTE
New in onset
Subarachnoid Hemorrhage
-Bleeding into the subarachnoid
space is usually due to a
ruptured saccular aneurysm or
AVM
-75 % due to anuerysm , 15 %
AVM
-Aneurysm : females 50-60y.0
-AVM : males , 20-40 y.o
Pathology : Aneurysm
•Congenital weakness of the vessel wall at sites
of branching
•20% multiple
•May be associated with other congenital
anomalies

22. Pathology : AV
Malformation
•Cause SAH in 10%
•Abnormal vessels bypass
the capillary system
•More often result in IC
hematoma than SAH

23. OTHER CAUSE OF ACUTE HEADACHE
-> SEIZURES as Post Ictal Phenomenon
-> Lumbar Puncture – increased in upright
position and relieved with recumbency ; due to
persistent CSF leak
--- Use small gauge needle and get only limited
amount of CSF
---- Lying flat after LP
Hypertensive Encephalopathy
Ocular Disorders - Angle Closure Glaucoma

24. Sexual Headaches
sexual excitement
Orgasmic
Post – orgasmic
Benign but SAH sometimes be excluded, self
limiting
Males > Females
Long foreplay or Abstinence may prevent

25. Classification
SUBACUTE
Weeks or months
Giant Cell Arteritis
• - temporal arteritis
• - Subacute granulomatous inflammation (lymphs,
neutrophils and giant cells )
• - 2x women } MEN
• - 50 Years and above
• - scalp tenderness, jaw claudication (pain / stiffness on
chewing)
• - blindness in 50 % due to involvement of opthalmic
artery
• - diagnosis – biopsy of thickened , dilated STA
Intracranial Lesions
• Brain Abscess – foci of infection, fever may
or may not be present
•Subdural Hematoma – elderly, alcoholic, ;
Hx of trauma ; waxing and waning S/S
• Brain tumors
•Diagnosis – CT scan and MRI
•LT - is contraindicated in most cases and
not very helpful
Neuralgia
•Trigeminal Neuralgia – V2, V3
•Glossopharyngeal Neuralgia –
swalllowing, may be associated with
syncopal attacks
•Post Herpetic Neuralgia – V1, vesicular
lesions or scar in distribution of nerve
•Diagnosis : Clinical; CT to R/O SOL

26. Classification
Migraine with Aura
Migraine without Aura
Cluster headache
Tension Type Headache
Cervical Spine Disease
Sinusitis
Dental Disease

27. Precipitating Factors

28. Prodomal Symptoms

29. Pain Characteristics

30. Location of Pain

31. Other features of headache

32. P.E : scalp , face, head
Vital signs Temperature, Pulse , cardiac
rate, BP
Weight loss, Malignancy
Skin Cutaneous lesions in
meningococcemia, herpes
zoster, AVM
Scalp Tenderness, nodularity,
erythema, signs of trauma,
tongue lacerations, bruits,
conjunctival injenction, Horners

33. NEUROLOGIC EXAMINATION
• MSE – confusion in SAH
• Focal deficits, in cranial nerve , motor and
sensory examination

34. Management
• Treatment should be directed at the cause of
acute headache

35. Treatment
• NSAIDs
• 5 Hydroxytriptamine Agonists
• High Flow Oxygen

36. Treatment
• Analgesic Withdrawal Headache – Oral Triptans
or Parenteral Dihydroergotamine if needed
• Cluster Headache – manage acute pain and
prevent subsequent ones with Sumatriptan or
Dihydroergotamine
• Tension-type Headache – may be managed using
same agents used for migraine; may respond to
aspirin, acetaminophen, NSAIDs, or
dihydroergotamine

37. Prophylactic Treatment
1. Beta Blockers
Ex: Propranolol
1. Tricyclic Antidepressants
Ex: Amitriptyline
1. Anticonvulsants
Ex: Valproic Acid
1. Calcium Channel Blockers – efficacious in the
prophylactic treatment of migraine
Ex: Verapamil, Nicardipine
1. Ergot Alkaloids
Ex: Methergine

38. Prophylactic Treatment
• Indicated for patients who
– have frequent headaches
– acute attacks that are difficult to manage
– those for whom symptomatic therapy is poorly
tolerated

39. When to Refer
• Frequent migraines not responsive to
standard therapy
• Migraines with atypical features
• Chronic daily headache due to medication
overuse

40. When to Refer
• Acute onset of “worst headache in my life”
• History of trauma, hypertension, fever, visual
changes
• Presence of neurologic siggns or of scalp
tenderness

41. When to Admit
• Need for repeated doses of parenteral pain meds
• To facilitate an expedited work-up requiring a
sequence of neuroimaging and procedures
• Monitoring for progression of symptoms and
neurologic consultation when the initial
emergency department work-up is inconclusive

42. When to Admit
• Pain severe enough to impair ADLs or limit
participation in follow-up appointments or
consultation
• Suspected subarachnoid hemorrhage or structural
intracranial lesions

43. THANK YOU