OPD approach to Pediatric headache

1. MIGRAINE - A HEADACHE FOR
PAEDIATRICIAN
Dr. Muzammil Koshish
MBBS DCH DNB(PAEDIATRICS)

2. z
Headache classification
• Primary headache
migraine, tension , cluster
• Secondary headache
Infection, trauma, hemorrhage, tumor, high
intracranial pressure.
• Cranial neuropathies

3. z
Migraine
• Episodic, periodic, paroxysmal attacks of modera
te to severe throbbing pain, separated by pain
free intervals,
• Associated with nausea, vomiting, photophobia,
abdominal pain and desire to sleep, motion sickn
ess.
• Family history 70-90%

4. z
Classification of migraine
(revised international headache society IHS 2004)
• Migraine without aura
• Migraine with aura

5. z
Migraine without aura (IHS 2004)
• A. at least 5 attacks fulfilling criteria B through D.
• B. Headache attacks lasting 4 to 72h
• C. headache has at least 2 of the following
-unilateral location
-pulsating quality
-moderate or severe pain intensity
-aggravation by or causing avoidence of
routine physical activity
• D. during headache at least one of the folowing:
nausea, vomiting, or both, photophobia, phonophobia
• E. not attributed to another disorder.

6. z
Migraine with aura (IHS 2004)
• A. at least 2 attacks fulfilling criteria B.
• B. migraine aura fulfilling criteria B or C for one of
the following subforms:
Typical aura with migraine headache
Typical aura with nonmigraine pain
Typical aura without headache
Familial hemiplegic migraine
Sporadic hemiplegic migraine
Basilar type migraine
• C. Not attributed to another disorder.

7. z
Childhood periodic syndromes
( precursors of migraine according to revised
HS criteria)
• Cyclic vomiting syndrome.
• Abdominal migraine.
• Benign paroxismal vertigo of childhood.

8. z
Clinical Evaluation
• Salient points in History
1. Headache characteristics
2. Trigger factors
3. Warning symptoms
4. Symptoms during attack
5. Relieving factors
6. Symptoms between attack
7. Family history

9. z
 Pattern of headache
1. Acute
2. Acute Recurrent
3. Chronic Progressive
4. Chronic Non-progressive

10. z
 Clues from clinical evaluation
1. Fever – URI and systemic infection
2. Weight loss – malignancy/tuberculosis
3. Neck rigidity – meningitis
4. Hypertension – renal/adrenal cause
5. Injuries – Trauma

11. z
Red Flag Signs
 Systemic signs and symptoms
 Neurologic signs and symptoms
 Sudden onset
 Occipital location
 Change in character of headache
 Age <6 years

12. z
When to perform neuroimaging
study ??
• Age < 6 years
• Abnormal neurological exam
• Chronic progressive pattern
• Family reassurance

13. z
MRI Vs CT
There was no sufficient data to make a
specific recommendation regarding
the relative sensitivity of MRI compar
ed with CT.
Most prefer MRI because of vascular
differential diagnosis.

14. z
EEG and migraine
• EEG is not indicated in the routine
evaluation of headache
• It is performed if seizures are
suspected.

15. z
Management of migraine
• Non-pharmacologic methods
1.Headache education
2.Lifestyle modification (Sleep,Meals,
Activity, Relaxation,Trigger avoidanc
e)
3.Biofeedback therapy (Relaxation
techniques, Hypnosis, Acupuncture,
Massage therapy)

16. z
Pharmacologic Treatment
• General pain medications
(acetaminophen, NSAIDS) alone or
in combination with antiemetic medi
cations
• Triptans-5HT1D agonists (Rizatriptan
, Almotriptan)

17. z
Indications for migraine
prophylaxis
• Attacks occur >2-4 times per month
• Disability occurs > 3 days per month
• Duration of attack > 48 h
• Medications for acute attack are ineff
ective, C.I or overused
• Attacks produce prolonged aura or
true migrainous infarction
• Patient preference

18. z
Duration of prophylactic
therapy
• The optimum duration of prophylact
ic therapy is uncertain
• The approach is to treat for 4-6 mo
nths and then taper over the course
of several weeks.

19. z
Preventive Therapy
• B blockers (Propranolol)
• Antihistaminic ( Cyproheptadine)
• Anticonvulsants (Topiramate, Valproi
c acid)
• Ca channel blocker (Flunarizine)

20. z
Key Messages
 History and detailed clinical examination
 Migraine is clinical diagnosis
 Identify Red Flags
 Neuroimaging only in suspected
secondary headache
 Lifestyle modification is an important part
of management

21. z
Thank you !