Management of Headaches in Children

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Management of Headaches in Children

  1. 1. Management of Headaches in ChildrenManagement of Headaches in Children Dr Nagi G BarakatDr Nagi G Barakat Consultant PaediatricianConsultant Paediatrician UKUK
  2. 2. Types of HeadachesTypes of Headaches  AcuteAcute  Acute recurrentAcute recurrent  Chronic progressiveChronic progressive  Chronic nonprogressiveChronic nonprogressive  Cluster headacheCluster headache  Epileptic headacheEpileptic headache  PsychogenicPsychogenic  MixedMixed
  3. 3. Acute HeadacheAcute Headache  It could be migraineIt could be migraine  Cerebrovascular bleedCerebrovascular bleed(CT or MRI with contrast)(CT or MRI with contrast)  Trauma (CT)Trauma (CT)  Meningitis (LP )Meningitis (LP )  Encephalitis (EEG and CT or MRI)Encephalitis (EEG and CT or MRI)  Drugs (urine toxicology)Drugs (urine toxicology)
  4. 4. Acute recurrentAcute recurrent  Migraine headacheMigraine headache  Patients history (recurrent pattern)Patients history (recurrent pattern) – Family historyFamily history – Visual auraVisual aura – NauseaNausea – Unilateral pain (throbbing)Unilateral pain (throbbing) – Gastrointestinal symptomsGastrointestinal symptoms – Exclude other causesExclude other causes
  5. 5. MigraineMigraine  Hippocrates described migraineHippocrates described migraine  Galen first used the term hemicraniaGalen first used the term hemicrania  Incidence 1.2% -3.2% at age of 7 years , and 4%-Incidence 1.2% -3.2% at age of 7 years , and 4%- 19% by age of 15 years19% by age of 15 years  More prevalent in femalesMore prevalent in females  Have genetic componentHave genetic component  2.8 school days per year lost as result of migraine2.8 school days per year lost as result of migraine  Children commonly have migraine without auraChildren commonly have migraine without aura  Children not usually having unilateral headacheChildren not usually having unilateral headache  Vasodilatation,vasoconstriction,oedema, andVasodilatation,vasoconstriction,oedema, and inflammation of cerebralinflammation of cerebral vessels produce painvessels produce pain
  6. 6. Causes of MigraineCauses of Migraine  The exact cause(s) of migraine headaches isThe exact cause(s) of migraine headaches is unknownunknown  Some migraines are thought to be due a temporarySome migraines are thought to be due a temporary deficiency of the brain chemical serotonindeficiency of the brain chemical serotonin » The most common triggers are alcohol, chocolate, cheese,The most common triggers are alcohol, chocolate, cheese, nuts, shellfish, Chinese food, sugar, and caffeine.nuts, shellfish, Chinese food, sugar, and caffeine.
  7. 7. Clinical features of migraineClinical features of migraine attackattack  ProdromeProdrome (change in mood or activity level)(change in mood or activity level)  **AuraAura( occurring in 10-50% of paediatric migraine( occurring in 10-50% of paediatric migraine attacks) Photopsia, scotoma, numbness, tingling, ataxia,attacks) Photopsia, scotoma, numbness, tingling, ataxia, dizziness, and vertigo.dizziness, and vertigo.  ** HeadacheHeadache(( Barlow et al, 300 pts with juvenile migraine,Barlow et al, 300 pts with juvenile migraine, only 9% of attacks were children awakened from sleep by the onest ofonly 9% of attacks were children awakened from sleep by the onest of a migraine and only 4% of attacks did they begin on awakening)a migraine and only 4% of attacks did they begin on awakening)  ResolutionResolution( headache may last 1-4hrs, sleep and( headache may last 1-4hrs, sleep and analgesic)analgesic)  PostdromePostdrome( Lethargy, anorexia and mood( Lethargy, anorexia and mood disturbances)disturbances)
  8. 8. Types of migraineTypes of migraine (HIS 1988)(HIS 1988)  Migraine with aura(Classical migraine)Migraine with aura(Classical migraine) It lasts from halfIt lasts from half an hour to 48 hours.an hour to 48 hours.  Migraine without aura (common migraine)Migraine without aura (common migraine) bilateral andbilateral and occurs in 60-85% of migrainous childrenoccurs in 60-85% of migrainous children  Chronic migraine:Chronic migraine: at least 15 days of every month for at leastat least 15 days of every month for at least 2 months. It may affect up to 4% of teenage girls and 2%2 months. It may affect up to 4% of teenage girls and 2% of teenage boys.of teenage boys.  Complicated migraine (hemiplegic migraine,Complicated migraine (hemiplegic migraine, ophthalmoplegic migraine,confusional migraine, Basilarophthalmoplegic migraine,confusional migraine, Basilar artery migraineartery migraine  Atypical forms of migraineAtypical forms of migraine – Cyclic vomitingCyclic vomiting – Recurrent abdominal painRecurrent abdominal pain
  9. 9. Abdominal migraineAbdominal migraine 1.1. The child may have recurrent bouts ofThe child may have recurrent bouts of generalized stomach pain with nausea andgeneralized stomach pain with nausea and vomitingvomiting 2.2. No headache is present. After severalNo headache is present. After several hours, the child can sleep and later feelhours, the child can sleep and later feel better.better. 3.3. Abdominal migraine may alternate withAbdominal migraine may alternate with typical migraine and usually leads totypical migraine and usually leads to typical migraine as the child maturestypical migraine as the child matures
  10. 10. Chronic non-progressiveChronic non-progressive Tension-Tension- Type HeadacheType Headache  This is the most common type of primary headache inThis is the most common type of primary headache in children,children,  Emotional factors are the most likely cause.Emotional factors are the most likely cause.  The pain is described as diffuse, sometimes like aThe pain is described as diffuse, sometimes like a tight band around the headtight band around the head  Is usually not associated with nausea or vomiting.Is usually not associated with nausea or vomiting.  These headaches are almost always related toThese headaches are almost always related to stressful situations at school, competition, familystressful situations at school, competition, family friction or excessive demands by parents.friction or excessive demands by parents.  Discussion with the child and parents is required toDiscussion with the child and parents is required to determine whether anxiety or depression may bedetermine whether anxiety or depression may be presentpresent
  11. 11. Chronic non-progressiveChronic non-progressive Tension headacheTension headache (2)(2) – At the end of the day on every day most daysAt the end of the day on every day most days – Often not responding to analgesia and may causeOften not responding to analgesia and may cause rebound headacherebound headache – Frequent school absenceFrequent school absence – More in femalesMore in females – Often respond to relaxation therapy and behaviouralOften respond to relaxation therapy and behavioural interventionintervention – Systematic review is importantSystematic review is important – Therapeutic planTherapeutic plan (check life style, school attendance(check life style, school attendance mandatory,counselling, behaviour and stress therapy andmandatory,counselling, behaviour and stress therapy and biofeedback is important)biofeedback is important)
  12. 12. Chronic progressiveChronic progressive  Daily headache with increase in severity andDaily headache with increase in severity and frequencyfrequency  Intercranial pathology should be suspectedIntercranial pathology should be suspected  Not responding to analgesiaNot responding to analgesia  May or may not associated with neurologicalMay or may not associated with neurological symptom and signssymptom and signs  May or may not associated with behaviouralMay or may not associated with behavioural problemsproblems  Need investigations including neuroimaging inNeed investigations including neuroimaging in most of patientsmost of patients  Benign intracranial hypertension should beBenign intracranial hypertension should be consideredconsidered
  13. 13. Brain TumourBrain Tumour  Uncommon in school-age childrenUncommon in school-age children  Incidence is 0.003%Incidence is 0.003%  AdditionalAdditional neurological symptoms and signs onneurological symptoms and signs on examinationexamination  Honig and Charney( 72 children with brain tumourHonig and Charney( 72 children with brain tumour – 94% with abnormal neurological examination94% with abnormal neurological examination – 85% with abnormalities on CNS examination within 2 months of85% with abnormalities on CNS examination within 2 months of presentationpresentation » Childhood brain Tumour consortiumChildhood brain Tumour consortium  3291 children with brain tumour3291 children with brain tumour  Headaches at time of diagnosis in 58% ofHeadaches at time of diagnosis in 58% of Supratontorial and 70% of InfratontorialSupratontorial and 70% of Infratontorial  99% of children with headaches and brain tumour99% of children with headaches and brain tumour had at least 1 abnormal neurological symptom andhad at least 1 abnormal neurological symptom and 98% had at least 1 abnormal neurological sign98% had at least 1 abnormal neurological sign
  14. 14. Bilateral optic nerveBilateral optic nerve swelling(Papilloedema)swelling(Papilloedema)
  15. 15. No enlargement of blind spot on visual fields
  16. 16. AstrocytomaAstrocytoma
  17. 17. MedulloblastomaMedulloblastoma

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