Childhood Headache 2


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Childhood Headache 2

  1. 1. Childhood Headache Rachel Howells
  2. 2. Learning Outcomes <ul><li>By the end of this session, you should be able to </li></ul><ul><li>Differentiate primary from secondary headache </li></ul><ul><li>Recognise and manage common primary headaches </li></ul>
  3. 3. Epidemiology <ul><li>Preschool </li></ul><ul><li>1/3 will have had a headache </li></ul><ul><li>Migraine headache 0-7% of population </li></ul><ul><li>Schoolchildren </li></ul><ul><li>70% have ≥ 1 headache a year </li></ul><ul><li>Peak at 90% at age 12-13 </li></ul><ul><li>Prevalence of recurrent headache 20-30% </li></ul>
  4. 4. Case 1
  5. 5. Case 1 <ul><li>15 year old girl </li></ul><ul><li>Frontal headache, down neck and shoulders </li></ul><ul><li>2 months </li></ul><ul><li>Start as soon as she rises from bed, and relieved by lying down </li></ul><ul><li>Missing school for 6 weeks </li></ul>
  6. 6. Primary or Secondary?
  7. 7. Case 1 <ul><li>Further history </li></ul><ul><li>Spinal surgery 3 months ago </li></ul><ul><li>Epidural anaesthesia </li></ul><ul><li>Examination </li></ul><ul><li>Normal </li></ul>
  8. 8. Low pressure headache <ul><li>Possible dural tap </li></ul><ul><li>Management </li></ul><ul><li>Encourage mobilising </li></ul><ul><li>Many spontaneously resolve within 3-4 months </li></ul><ul><li>Short-term: Caffeine </li></ul><ul><li>Long-term: Epidural blood patch </li></ul>
  9. 9. Primary vs Secondary Headache
  10. 10. Primary vs Secondary Headache <ul><li>10% of headaches seen in a specialist neurology / headache clinic are secondary in origin </li></ul><ul><li>Population prevalence of organic disease is likely to be lower </li></ul>
  11. 11. Secondary Headache Types Altered Intracranial Pressure Raised ICP Low Pressure Headaches Vascular Subarachnoid Headache (eg AVM) Dissection Vasculitis Drugs Drug effect Analgesia induced headache Central (thalamic) pain Trigeminal neuralgia Cluster headaches Local Dental Abscess Sinusitis Post head injury
  12. 12. How to identify a secondary headache
  13. 13. How to identify a secondary headache Brain Imaging Examination History
  14. 14. Indications that a headache is secondary to altered intracranial pressure
  15. 15. Indications <ul><li>Timing of headache </li></ul><ul><li>Postural manoeuvres </li></ul><ul><li>Associated symptoms </li></ul>
  16. 16. Timing of Headache Morning but from sleep, before rising Raised Intracranial Pressure Morning but after getting up Low Pressure Headache
  17. 17. Postural Manoeuvres Getting up relieves headache Coughing and straining exacerbates it Raised Intracranial Pressure Lying down relieves headache Low Pressure Headache or Sinusitis
  18. 18. Associated Symptoms Frontal headache Associations Morning vomiting Other neurology Confusion Raised Intracranial Pressure Frontal headache Associations Pain / parasthesiae across shoulders* Blocked nose, facial pain ¤ Low Pressure Headache* or Sinusitis ¤
  19. 19. Case 2
  20. 20. Case 2 <ul><li>16 year old girl seen in OPD </li></ul><ul><li>Frontal headache </li></ul><ul><li>There when she wakes, gets better when she gets up </li></ul><ul><li>No nausea or other neurological symptoms </li></ul><ul><li>4 months, not getting any worse </li></ul>
  21. 21. Primary or Secondary? Is this raised or low intracranial pressure?
  22. 22. Case 2 continued <ul><li>Past History – nil </li></ul><ul><li>Examination </li></ul><ul><li>Enlarged blind spots on confrontation </li></ul><ul><li>No other alteration of visual fields </li></ul><ul><li>Papilloedema </li></ul><ul><li>No ataxia, long tract signs </li></ul>
  23. 23. What diagnoses need to be considered?
  24. 24. Causes of Raised Intracranial Pressure Hydrocephalus Tumour obstructing CSF pathways Obstruction to CSF re-absorption (post haemorrhage or meningitis) Congenital (eg aqueduct stenosis) Cerebral oedema Inflammation (ADEM, stroke) Infection (meningitis etc) CO2 retention (obstructive sleep apnoea) Metabolic (DKA, other) Idiopathic (Benign) Intracranial Hypertension
  25. 25. Idiopathic Intracranial Hypertension <ul><li>Aetiology unknown </li></ul><ul><li>Adolescent girls </li></ul><ul><li>Obesity, drugs, steroid withdrawal </li></ul><ul><li>Visual loss (10%) may be permanent and is only indication for treatment </li></ul>Raised intracranial pressure in the absence of space occupying lesion or obstruction to CSF flow
  26. 26. Indications <ul><li>Timing of headache </li></ul><ul><li>Postural manoeuvres </li></ul><ul><li>Associated symptoms </li></ul>
  27. 27. Case 3
  28. 28. Case 3 <ul><li>14 year old girl </li></ul><ul><li>Headache since the evening before </li></ul><ul><li>Single and worst headache ever </li></ul><ul><li>Sudden onset </li></ul><ul><li>Vomited once at start </li></ul><ul><li>No history of head injury / prodrome </li></ul>
  29. 29. Case 3 <ul><li>Examination </li></ul><ul><li>Afebrile </li></ul><ul><li>No meningism </li></ul><ul><li>GCS 15 </li></ul><ul><li>Unilateral facial weakness with frontal sparing </li></ul><ul><li>Ipsilateral arm weakness with hyporeflexia </li></ul>
  30. 30. What diagnoses should you entertain?
  31. 31. CT brain
  32. 32. Case 3 <ul><li>CT shows haemorrhage around area of left basal ganglia </li></ul><ul><li>Patient admits to using some cocaine at a party with her 18 year-old sister </li></ul>
  33. 33. More information to help you identify secondary headache History
  34. 34. Timecourse Single or first severe headache Recurrent severe headaches One a month 2 years without progression Headaches all day on most days 18 months Headaches every few months then weeks then days Now every day Severe headaches all day for 12 days 2 months ago None since Bleed? Bleed? Tumour? TTH? Migraine?
  35. 35. Timecourse Single or first severe headache Recurrent severe headaches One a month 2 years without progression Headaches all day on most days 18 months Headaches every few months then weeks then days Now every day Severe headaches all day for 12 days 2 months ago None since
  36. 36. Pointers in History: Summary <ul><li>Timing of Headache </li></ul><ul><li>Postural manoeuvres </li></ul><ul><li>Symptoms associated with headache </li></ul><ul><li>Timecourse </li></ul>
  37. 37. Examination
  38. 38. Purpose of Examination <ul><li>To support your clinical impression made on history </li></ul><ul><li>To rule out other differentials </li></ul><ul><li>To adhere to many families expectations </li></ul><ul><ul><ul><li>to be taken seriously </li></ul></ul></ul><ul><ul><ul><li>to be able to support your view that nothing serious is going on </li></ul></ul></ul>
  39. 39. Essential elements of Examination Vision Acuity Fields including blind spot Extraocular movements Long tract signs Tone Power Reflexes Cerebellar signs Finger-nose test (eyes shut) Tremor Dysarthria Gait Blood pressure Bruit Conscious level Fundi
  40. 40. Case 4
  41. 41. Case 4 <ul><li>8 year old boy with 10 month history of </li></ul><ul><li>Bi-temporal headache </li></ul><ul><li>Throbbing </li></ul><ul><li>Worse with movement / exercise </li></ul><ul><li>Mother says looks pale and unwell </li></ul><ul><li>Usually start in morning </li></ul><ul><li>Last all day </li></ul>
  42. 42. Case 4 <ul><li>No family history </li></ul><ul><li>Examination is normal </li></ul>
  43. 43. Primary or Secondary? What is the most likely diagnosis?
  44. 44. Migraine without aura
  45. 45. What causes migraine? <ul><li>Migraine headache </li></ul><ul><li>Nerve efferents – trigeminal, vagal </li></ul><ul><li>Meninges have pain fibres with inputs from trigeminal complex </li></ul><ul><li>Vasodilation of meningeal vessels </li></ul>Michael Creighton <ul><li>Why do some people get migraine headaches? </li></ul><ul><li>Genetic </li></ul><ul><li>Abnormal inhibitory inputs to trigeminal nerve complex </li></ul>
  46. 46. Clinical Implications <ul><li>Abnormal inhibition to nociceptive parts of brain </li></ul><ul><li>Abnormal response to changes in environment eg sleep, diet, smells </li></ul><ul><li>Pain is exacerbated by noise and light </li></ul><ul><li>Headache relieved by sleep in a dark room </li></ul><ul><li>Migraine symptoms </li></ul><ul><li>Pain involves the face (trigeminal) </li></ul><ul><li>Throbbing pain (meningeal) </li></ul><ul><li>Pallor and nausea (vagal) </li></ul>Delia Malchert
  47. 47. Migraine <ul><li>Classification </li></ul><ul><li>Migraine without aura (commonest) </li></ul><ul><li>Migraine with aura </li></ul><ul><li>Basilar migraine </li></ul><ul><li>Ophthalmoplegic migraine </li></ul><ul><li>Alternating hemiplegia </li></ul>
  48. 48. Migraine <ul><li>The diagnosis is a clinical one </li></ul><ul><li>Families can be reassured by </li></ul><ul><li>Family history </li></ul><ul><li>Longevity of symptoms </li></ul><ul><li>Normal examination </li></ul><ul><li>Addressing their underlying concerns </li></ul>
  49. 49. Management <ul><li>Explanation </li></ul><ul><li>This is not a tumour </li></ul><ul><li>Worst in second decade of life </li></ul><ul><li>Most patients will get fewer headaches as they get older </li></ul>
  50. 50. Management <ul><li>2. Treatment of attacks </li></ul><ul><li>Analgesia as soon as an attack starts </li></ul><ul><li>Ibuprofen works best (one RCT) </li></ul><ul><li>May be supplemented by anti-emetic </li></ul><ul><li>Patients over 12 may respond to im, oral or nasal sanomigran (Imigran) </li></ul>
  51. 51. Management <ul><li>3. Prevention – control of environment </li></ul><ul><li>‘ Sleep hygiene’ – regular sleep </li></ul><ul><li>‘ Diet hygiene’ – avoid long breaks ± snack before bed, avoid caffeine, low amine diet </li></ul><ul><li>‘ Exercise hygiene’ – regular exercise, maintain hydration </li></ul><ul><li>Avoid stress – relaxation training, CBT </li></ul>
  52. 52. Management <ul><li>4. Prevention – pharmacological </li></ul><ul><li>No magic bullet, trial basis only </li></ul><ul><li>Pizotifen </li></ul><ul><li>Propanolol </li></ul><ul><li>Feverfew </li></ul>
  53. 53. Case 5
  54. 54. Case 5 <ul><li>10 year-old girl with 18 month history of </li></ul><ul><li>Bilateral headache, mainly vertex </li></ul><ul><li>Constant </li></ul><ul><li>Comes on during day </li></ul><ul><li>Not worsened by walking </li></ul><ul><li>No aura or pallor / nausea </li></ul><ul><li>5/7 days a week, most weeks of the year </li></ul>
  55. 55. Case 5 <ul><li>No family history </li></ul><ul><li>Examination normal </li></ul><ul><li>Local grammar school </li></ul><ul><li>Predicted for A grades in 10 GSCEs </li></ul><ul><li>No external sources of anxiety – stable home, not being bullied </li></ul><ul><li>Trying to keep going to school </li></ul>
  56. 56. Case 5 <ul><li>Alternating ibuprofen 400mg and co-codamol for headaches </li></ul><ul><li>‘ Nothing really works’ </li></ul>
  57. 57. Primary or secondary? What is the most likely diagnosis?
  58. 58. Chronic Tension-Type Headache
  59. 59. How is the diagnosis made?
  60. 60. CTTH <ul><li>No features suggestive of organic disease </li></ul><ul><ul><ul><li>Time of day </li></ul></ul></ul><ul><ul><ul><li>Postural manoeuvres </li></ul></ul></ul><ul><ul><ul><li>Associated symptoms </li></ul></ul></ul><ul><ul><ul><li>Time course </li></ul></ul></ul><ul><li>Not classifiable as migraine </li></ul><ul><li>Examination normal </li></ul>
  61. 61. Management <ul><li>Explanation </li></ul><ul><li>Although not an organic disease, effects on life can be significant (school etc) </li></ul><ul><li>Treat attacks </li></ul><ul><li>Simple analgesia </li></ul><ul><li>Avoid multiple drugs </li></ul><ul><li>Feverfew / Levomenthol / TigerBalm </li></ul>
  62. 62. Management <ul><li>Prevention of attacks </li></ul><ul><li>Sleep, diet, exercise hygiene </li></ul><ul><li>Address anxiety (relaxation training, CBT) </li></ul><ul><li>Maintain contact with school, try and attend but manage workload </li></ul>
  63. 63. What did you learn? <ul><li>You should now be able to </li></ul><ul><li>Differentiate primary from secondary headache </li></ul><ul><li>Recognise and manage common primary headaches </li></ul><ul><ul><ul><li>Migraine with / without aura </li></ul></ul></ul><ul><ul><ul><li>Tension-type headache </li></ul></ul></ul>
  64. 64. Any questions?
  65. 65. Thank you for listening Rachel Howells