1. The document discusses differentiating primary from secondary headaches and recognizing common childhood headaches like migraine and tension-type headaches. 2. Case examples are presented to demonstrate distinguishing features of different headache types based on history, examination, and diagnostic testing. 3. Management involves treatment of acute headaches, prevention strategies, and addressing triggers or comorbidities depending on the diagnosis.

1. Childhood Headache Rachel Howells

2. Learning Outcomes By the end of this session, you should be able to Differentiate primary from secondary headache Recognise and manage common primary headaches

3. Epidemiology Preschool 1/3 will have had a headache Migraine headache 0-7% of population Schoolchildren 70% have ≥ 1 headache a year Peak at 90% at age 12-13 Prevalence of recurrent headache 20-30%

4. Case 1

5. Case 1 15 year old girl Frontal headache, down neck and shoulders 2 months Start as soon as she rises from bed, and relieved by lying down Missing school for 6 weeks

6. Primary or Secondary?

7. Case 1 Further history Spinal surgery 3 months ago Epidural anaesthesia Examination Normal

8. Low pressure headache Possible dural tap Management Encourage mobilising Many spontaneously resolve within 3-4 months Short-term: Caffeine Long-term: Epidural blood patch

9. Primary vs Secondary Headache

10. Primary vs Secondary Headache 10% of headaches seen in a specialist neurology / headache clinic are secondary in origin Population prevalence of organic disease is likely to be lower

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. How to identify a secondary headache

13. How to identify a secondary headache Brain Imaging Examination History

14. Indications that a headache is secondary to altered intracranial pressure

15. Indications Timing of headache Postural manoeuvres Associated symptoms

16. Timing of Headache Morning but from sleep, before rising Raised Intracranial Pressure Morning but after getting up Low Pressure Headache

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. 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. Case 2

20. Case 2 16 year old girl seen in OPD Frontal headache There when she wakes, gets better when she gets up No nausea or other neurological symptoms 4 months, not getting any worse

21. Primary or Secondary? Is this raised or low intracranial pressure?

22. Case 2 continued Past History – nil Examination Enlarged blind spots on confrontation No other alteration of visual fields Papilloedema No ataxia, long tract signs

23. What diagnoses need to be considered?

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. Idiopathic Intracranial Hypertension Aetiology unknown Adolescent girls Obesity, drugs, steroid withdrawal Visual loss (10%) may be permanent and is only indication for treatment Raised intracranial pressure in the absence of space occupying lesion or obstruction to CSF flow

26. Indications Timing of headache Postural manoeuvres Associated symptoms

27. Case 3

28. Case 3 14 year old girl Headache since the evening before Single and worst headache ever Sudden onset Vomited once at start No history of head injury / prodrome

29. Case 3 Examination Afebrile No meningism GCS 15 Unilateral facial weakness with frontal sparing Ipsilateral arm weakness with hyporeflexia

30. What diagnoses should you entertain?

31. CT brain

32. Case 3 CT shows haemorrhage around area of left basal ganglia Patient admits to using some cocaine at a party with her 18 year-old sister

33. More information to help you identify secondary headache History

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. 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. Pointers in History: Summary Timing of Headache Postural manoeuvres Symptoms associated with headache Timecourse

37. Examination

38. Purpose of Examination To support your clinical impression made on history To rule out other differentials To adhere to many families expectations to be taken seriously to be able to support your view that nothing serious is going on

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. Case 4

41. Case 4 8 year old boy with 10 month history of Bi-temporal headache Throbbing Worse with movement / exercise Mother says looks pale and unwell Usually start in morning Last all day

42. Case 4 No family history Examination is normal

43. Primary or Secondary? What is the most likely diagnosis?

44. Migraine without aura

45. What causes migraine? Migraine headache Nerve efferents – trigeminal, vagal Meninges have pain fibres with inputs from trigeminal complex Vasodilation of meningeal vessels Michael Creighton Why do some people get migraine headaches? Genetic Abnormal inhibitory inputs to trigeminal nerve complex

46. Clinical Implications Abnormal inhibition to nociceptive parts of brain Abnormal response to changes in environment eg sleep, diet, smells Pain is exacerbated by noise and light Headache relieved by sleep in a dark room Migraine symptoms Pain involves the face (trigeminal) Throbbing pain (meningeal) Pallor and nausea (vagal) Delia Malchert

47. Migraine Classification Migraine without aura (commonest) Migraine with aura Basilar migraine Ophthalmoplegic migraine Alternating hemiplegia

48. Migraine The diagnosis is a clinical one Families can be reassured by Family history Longevity of symptoms Normal examination Addressing their underlying concerns

49. Management Explanation This is not a tumour Worst in second decade of life Most patients will get fewer headaches as they get older

50. Management 2. Treatment of attacks Analgesia as soon as an attack starts Ibuprofen works best (one RCT) May be supplemented by anti-emetic Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)

51. Management 3. Prevention – control of environment ‘ Sleep hygiene’ – regular sleep ‘ Diet hygiene’ – avoid long breaks ± snack before bed, avoid caffeine, low amine diet ‘ Exercise hygiene’ – regular exercise, maintain hydration Avoid stress – relaxation training, CBT

52. Management 4. Prevention – pharmacological No magic bullet, trial basis only Pizotifen Propanolol Feverfew

53. Case 5

54. Case 5 10 year-old girl with 18 month history of Bilateral headache, mainly vertex Constant Comes on during day Not worsened by walking No aura or pallor / nausea 5/7 days a week, most weeks of the year

55. Case 5 No family history Examination normal Local grammar school Predicted for A grades in 10 GSCEs No external sources of anxiety – stable home, not being bullied Trying to keep going to school

56. Case 5 Alternating ibuprofen 400mg and co-codamol for headaches ‘ Nothing really works’

57. Primary or secondary? What is the most likely diagnosis?

58. Chronic Tension-Type Headache

59. How is the diagnosis made?

60. CTTH No features suggestive of organic disease Time of day Postural manoeuvres Associated symptoms Time course Not classifiable as migraine Examination normal

61. Management Explanation Although not an organic disease, effects on life can be significant (school etc) Treat attacks Simple analgesia Avoid multiple drugs Feverfew / Levomenthol / TigerBalm

62. Management Prevention of attacks Sleep, diet, exercise hygiene Address anxiety (relaxation training, CBT) Maintain contact with school, try and attend but manage workload

63. What did you learn? You should now be able to Differentiate primary from secondary headache Recognise and manage common primary headaches Migraine with / without aura Tension-type headache

64. Any questions?

65. Thank you for listening Rachel Howells