Headaches Practical approach

Dr Maltby

Chronic Headache

Migraine Tension headaches/chronic daily headaches Teeth/Nocturnal grinding Sinus congestion Visual Sleep apnoea Benign Occipital Epilepsy BIH Raised intracranial pressure

When to scan

Very young children Change in the character of headaches History suggestive of raised ICP Focal neurological Signs Papillodema – not optic detrusum Headache with erratic vomiting FH or anxiety of IC lesion BIH with optic nerve views

Mausley Study

Very old study 1998 Looked at children with CNS tumours mode of referral and the symptoms Majority DID NOT have symptoms classically of raised ICP Majority DID NOT have focal neurology Majority had frequently been seen by GP paediatricians and even a paediatric neurologist

Conclusions

Falsely reassured by normal examination Signs of ICP are great but don’t help Change in character in under 5 School failure in over 5

Migraine

Episodes headaches relief with sleep Vomiting Visual disturbance- specific Pallor FH Motion sickness Neurological symptoms vary Between times pain free

Management

Examination normal Scan if under 5 Advice about treating the acute attack Isolating triggers avoidance if possible Multiple

Triggers

Dietary – dairy, citrus, tomatoes, blackcurrant, fizzy drinks – J2O Sleep – excessive weekend lyins or sleep overs Excitement Stressed out Busy life

Busy lives

After school clubs Sibs after school clubs Weekend activity Sleep overs Home work – plans/supervision Friendships Sport activities Rushing mothers

Management of acute attack

Immediate analgesia- emergency protocol Write to the school for their support Ibrufen, Migraleve If vomiting Migraleve Very rare to need Sumitryptin Monitor school attendance maybe late attendance better than none

Preventive management

Depend on the frequency school attendance Diet exclusion Recognise triggers Pziotifen Others treatments- Topiramate, Epilum,Gabapentin, Amitriptyline

Chronic daily headache

Teenagers High achievers Driven from within not by school/parents Lots of mates- squabble or miss no mates Area of stress in family home Not helped by analgesia Never wake with headache but have it at night Most difficult to manage

Management General advice

Fluid intake Regular meals- diet restrictions Regular exercise Regular sleep patterns – lying in!

TV and computer usage Analgesia usage Normalising life After school clubs and in sibs Avoid asking” do you have a headache” Family attitude to illness

Explanation Stressy teenagers learn to relax- pilartes Advice about studying Driven from within Learn to live with it

Treatment strategies

Dietary exclusion – formally not by diary Diary – shocking what they eat Exclude for 6 weeks:         Diary products Citrus/Apples in any form Tomatoes and ketchup Fizzy drinks Blackcurrant drinks Chocolate Marmite Anything else you can think of especially if the love them Replace one thing every 4 days if there was a response

Medication

Diet fails or the child cheats or refuses Explanation of pain modification the pain is there but the response is different Trail of Pziotfen ONLY at night – for at least 6 weeks Topiramate Gabapentin Epilum

Alternative treatements

Butterbur Migraine support group Headache clinics CAMS

BIH

DO not diagnosis this unless confirmed papillodeama and optic nerve swelling on MRI Reproducible reduction in visual acuity Formal visual fields assessment is poor even in teenager Child has a risk factor – obesity and tetracycline usage

Diagnosis

Raised pressure on opening at LP Not under GA straightened legs Pressure above 20 Therapeutic and diagnostic procedure so reduce pressure to 20 if over 40 then halve it Dramatic response to LP in terms of treatment

Pitfalls

Repeated LP Refusal to allow it without a GA Symptoms from LP confuse the picture Side effects from the Diamox Evidence that evolves residual chronic daily headache Bolt monitoring

Questions?

Hard work

Fits Faints and Funny turns

Noah

18 months Three episodes when his mother says he is found on the floor unresponsive floor and jerks lasts about 30mins but father thinks less.

Preceded by a cry After he appears confused and inconsolable EEG performed by the SHO after being seen in A/E- normal ECG normal QTc 0.42sec

24hr ECG normal FH father used to do this as a child and was treated with Phenytoin Comes to discuss if they should give a trail of anticonvulsant

Ellie

12 years of age C/O fit at school Fat lasting 5 minutes witness by the first aider (whose sister used to have fits) Called 999 by the maths teacher was sick and confused afterwards In A/E now feeling better fully conscious a slight headache B?S by paramedics 6.5

PMH febrile convulsion resulting in an PICU admission for 24 hours given rectal diazepam that mother still carries FH Mother has epilepsy on Tegretol Exam normal No focal signs to find One café au lait spot Referred to you asking if they could attend first fit clinic and an EEG has been organised

Part two - clinic

Further episode occurred during home tec and at home witness by her older sister School refuse to have her back unless “some things is done” Mother is sleeping in her bedroom on the floor EEG –non specfic changes has occasional spikes

MAX

4 years of age- 8 daily episodes cries sits down goes rigid eyes roll back lasting 2mins then confused afterwards for a bout 30mins.

Described as pale Max says he feels dizzy before hand.

Neurodevelopmental normal No other reported problems – absence episodes reported by the nursery but not noted at home PMH – sinus bradycardia as neonate seen by Cardiologist at GOS happy with him Examination normal HR 70 nil else Echo normal ECG normal Normal QTc -0.44sec

24hour tape mum went to anyway not cancelled

Differential diagnosis of a seizure

Syncope Vasovagal Cardiac causes- cardiomyopathy/prolonged QTc Breath holding Reflex anoxic seizures/ Reflex anoxic syncope Psuedo sezuires Emotional syncope Valsalva/ constipation Stereotypical behaviours Tics Gratification habits Basilar migraine Paroxysmal spasmodic torticollis Benign paroxysmal vertigo

TAKE A HISTORY THE EVENT AND THE RUN UP AND AFTER.

If your not sure adopt watchful waiting DO NOT order an EEG unless you think it will give you information and interoperated the information with the clinical case Give advice

1. What are the risk for a reoccurrence after one seizure? After two seizures?

2. What should you tell them to do at school?

3. Whats the advice regarding swimming?

4. Whats the advice about sleeping arrangements?

5. Whats to do about TV and computer games?

6. Any other advice?

7. You reg wants to give them Midazolam prescribe it?

Is the episode a seizures?

What’s the cause of the seizure?

Is this epilepsy?

What is the cause of the epilepsy? --------- NOW think EEG Classify epilepsy into a syndrome?

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