Pediatric Headache Evaluation and Treatment Guide

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

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

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)

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
 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

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

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

Pediatric Headache Evaluation and Treatment Guide

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