Transcript Childhood Headache - Royal Devon and Exeter Hospital

Childhood Headache
Rachel Howells
Learning Outcomes
By the end of this session, you should be
able to
Differentiate primary from secondary
headache
 Recognise and manage common primary
headaches

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%
Case 1
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

Primary or Secondary?
Case 1
Further history
 Spinal surgery 3 months ago
 Epidural anaesthesia
Examination
 Normal
Low pressure headache
Possible dural tap
Management
 Encourage mobilising
 Many spontaneously resolve within 3-4
months
 Short-term: Caffeine
 Long-term: Epidural blood patch
Primary vs Secondary
Headache
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
Secondary Headache Types
Altered Intracranial Pressure
Raised ICP
Low Pressure Headaches
Drugs
Drug effect
Analgesia induced headache
Vascular
Subarachnoid Headache (eg AVM)
Dissection
Vasculitis
Central (thalamic) pain
Local
Trigeminal neuralgia
Cluster headaches
Dental Abscess
Sinusitis
Post head injury
How to identify a
secondary headache
How to identify a
secondary headache
History
Examination
Brain Imaging
Indications that a headache
is secondary to altered
intracranial pressure
Indications
1.
2.
3.
Timing of headache
Postural manoeuvres
Associated symptoms
Timing of Headache
Morning but from sleep,
before rising
Morning but
after getting up
Raised
Intracranial Pressure
Low Pressure
Headache
Postural Manoeuvres
Getting up relieves
headache
Lying down
relieves headache
Coughing and straining
exacerbates it
Raised
Intracranial Pressure
Low Pressure
Headache or
Sinusitis
Associated Symptoms
Frontal headache
Frontal headache
Associations
Morning vomiting
Other neurology
Confusion
Associations
Pain / parasthesiae
across shoulders*
Blocked nose, facial pain¤
Raised
Intracranial Pressure
Low Pressure
Headache* or
Sinusitis¤
Case 2
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
Primary or Secondary?
Is this raised or low intracranial pressure?
Case 2 continued
Past History – nil
Examination
 Enlarged blind spots on confrontation
 No other alteration of visual fields
 Papilloedema

No ataxia, long tract signs
What diagnoses need to be
considered?
Causes of Raised Intracranial
Pressure
Hydrocephalus
Tumour obstructing CSF pathways
Obstruction to CSF re-absorption
(post haemorrhage or meningitis)
Congenital (eg aqueduct stenosis)
Idiopathic (Benign)
Intracranial
Hypertension
Cerebral oedema
Inflammation (ADEM, stroke)
Infection (meningitis etc)
CO2 retention (obstructive sleep apnoea)
Metabolic (DKA, other)
Idiopathic Intracranial Hypertension
Raised intracranial pressure
in the absence of space occupying lesion
or obstruction to CSF flow
Aetiology unknown
 Adolescent girls
 Obesity, drugs, steroid withdrawal
 Visual loss (10%) may be permanent and
is only indication for treatment
Indications
1.
2.
3.
Timing of headache
Postural manoeuvres
Associated symptoms
Case 3
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
Case 3
Examination
 Afebrile
 No meningism
 GCS 15
Unilateral facial weakness with frontal
sparing
 Ipsilateral arm weakness with hyporeflexia

What diagnoses should you
entertain?
CT brain
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
More information to help
you identify secondary
headache
History
Timecourse
Migraine?
Single or first
severe headache
Bleed?
Headaches all day
on most days
18 months
TTH?
Recurrent severe headaches
One a month
2 years without progression
Headaches every few months
then weeks
then days
Now every day
Tumour?
Severe headaches all day for 12 days
2 months ago
None since
Bleed?
Timecourse
Single or first
severe headache
Headaches all day
on most days
18 months
Recurrent severe headaches
One a month
2 years without progression
Headaches every few months
then weeks
then days
Now every day
Severe headaches all day for 12 days
2 months ago
None since
Pointers in History: Summary
1.
2.
3.
4.
Timing of Headache
Postural manoeuvres
Symptoms associated with headache
Timecourse
Examination
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
Essential elements of Examination
Conscious level Vision
Acuity
Fields including blind spot
Long tract signs
Extraocular movements
Tone
Power
Cerebellar signs
Reflexes
Finger-nose test (eyes shut)
Blood pressure
Bruit
Tremor
Dysarthria
Gait
Fundi
Case 4
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

Case 4
No family history
Examination is normal
Primary or Secondary?
What is the most likely diagnosis?
Migraine without aura
What causes migraine?
Migraine headache
 Nerve efferents – trigeminal,
vagal
 Meninges have pain fibres with
inputs from trigeminal complex
 Vasodilation of meningeal vessels
Why do some people get migraine
headaches?

Genetic

Abnormal inhibitory inputs to
trigeminal nerve complex
Michael Creighton
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
Delia Malchert
Migraine symptoms
 Pain involves the face
(trigeminal)
 Throbbing pain (meningeal)
 Pallor and nausea (vagal)
Migraine
Classification
 Migraine without aura (commonest)
 Migraine with aura
Basilar migraine
 Ophthalmoplegic migraine
 Alternating hemiplegia

Migraine
The diagnosis is a clinical one
Families can be reassured by
 Family history
 Longevity of symptoms
 Normal examination
 Addressing their underlying concerns
Management
1.
Explanation

This is not a tumour
Worst in second decade of life
Most patients will get fewer headaches
as they get older


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)
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

Management
4. Prevention – pharmacological
No magic bullet, trial basis only
 Pizotifen
 Propanolol

Feverfew
Case 5
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
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

Case 5
Alternating ibuprofen 400mg and
co-codamol for headaches
 ‘Nothing really works’

Primary or secondary?
What is the most likely diagnosis?
Chronic Tension-Type
Headache
How is the diagnosis
made?
CTTH

No features suggestive of organic disease
 Time
of day
 Postural manoeuvres
 Associated symptoms
 Time course
Not classifiable as migraine
 Examination normal

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
Management
Prevention of attacks
Sleep, diet, exercise hygiene
 Address anxiety (relaxation training, CBT)
 Maintain contact with school, try and
attend but manage workload

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
Any questions?
Thank you for listening
Rachel Howells