Headache Flashcards
What are the differentials for headache?
Migraine
Tension headache
Brain tumor
Pseudotumor cerebri
Acute sinusitis
Most frequent type of recurrent headache?
Migraine
What is the etiology of migraine?
Etio
- during adolescence, more common in F
- <10yo, more common in M
- >10yo, >50% undergo spontaneous prolonged
remission
- Most frequent type of recurrent headache
- Risk factors: use of late night electronics (blue light and
melatonin), poor sleep hygiene, poor hydration, erratic
meals, caffeine, lack of routine exercise, stress and
depression, medication overuse
What is the pathophysiology of migraine?
Patho
- Migraine is thought to be a NV pain syndrome with
altered central neuronal processing (activation of BS
nuclei, cortical hyperexcitability, spreading cortical
depression) and involvement of the trigeminovascular
system (triggering peptide release) causing painful
inflammation in cranial vessels and dura mater.
What are the clinical manifestations of migraine?
CM
1. Episodic attacks moderate to severe, focal, throbbing
2. Nausea, vomiting, light and sound sensitivity
3. Aura: complex of focal neuro sx that initiates or
accompanies an attack
- Develops over 5-20 min and lasts <60min
- Visual, sensory, motor, language, brainstem
What are the different types migraine?
Type
1. Migraine without aura
- Most prevalent type
- Throbbing or pounding, unilateral, aggravated by mov,
mod to severe
- Bifrontal or temporal areas
- Intense nausea and vomiting
- (+)FHx (90%) maternal side
- Light-headedness, photophobia, osmophobia,
phonophobia (???)
2. Migraine with aura
- At least 5 attacks lasting 2-72h (age <18yo) plus any 2
of the ff:
o Unilateral or bilateral location in children
<18yo and often frontal
o Pulsating quality
o Moderate or severe pain intensity
o Aggravation by or causing avoidance of
routine physical activity
- During the headache, at least 1 of the ff occurs:
o Nausea and/or vomiting
o Photophobia and phonophobia
a. Typical – visual/sensory/dysphasic
b. Atypical – hemiplegic/ Alice in wonderland
c. Cyclic vomiting – recurrent, severe vomiting
(>5x/h) in infants for 1-5d
§ After deep sleep, child resumes
normal play
§ Complete resolution of sx
between attacks
d. Abdominal migraine – mid-abdominal pain
with pain-free episodes between attacks
§ at time of abd pain, >2 of the ff:
* anorexia
* nausea
* vomiting
* pallor
* pain x 1-72h
e. Hemiplegic aura – unilateral sensory or
motor signs that may persist for days
§ Good prognosis in older
child/adolescent
f. Basilar-type migraine – vasoconstriction of
basilar and posterior cerebral arteries
§ Vertigo, tinnitus, diplopia,
scotoma, ataxia
§ Altered consciousness with sz
§ F <4yo
§ occipital
Diagnostics for migraine?
Indication of Neuroimaging (cranial MRI)
1. Abnormal neurologic examination
2. Abnormal or focal neurologic s/sx
3. Seizures or very brief auras (<5m)
4. Unusual headaches in children
a. Atypical auras: basilar type, hemiplegic
b. Trigeminal autonomic cephalagia including
cluster headaches
c. Acute secondary headache
5. Brief cough headache
6. Headache is worse upon waking or awakens child from
sleep
7. Migrainous headache in a child with no FHx of migraine
or its equivalent
Management of migraine?
Mgt
3 Components in Migraine Mgt
1. Acute tx should be developed for stopping a headache
attack on a consistent basis with return to function
within a maximum of 2h
2. Preventive tx when headaches are frequent (>1/week)
and disabling
3. Behavior tx
Acute Tx
1. NSAID – for mild to mod, restrict attack not more than
4d/week or 15d/month (avoid medication overuse
headache), q3-4h
- Paracetamol 15mkdose q4-6h
- Ibuprofen 7.5mkdose q6-8h
- Naproxen 10-20mkdose q12h
- ASA >15yo
2. Triptans – if mod to severe or NSAID fails; q2h
- SE: tightness of jaw, chest, fingers due to vascular
constriction, feeling of grogginess, and fatigue to
central serotonin effect
- Almotriptan, Rizatriptan
- Sumatriptan (10mg) plus naproxen (85mg): most
effective combination
3. Restrict to not more than 4-6 attacks/mo
4. Fluid hydration – for vascular dilation
5. Status migrainosus – persistent headache >3d. Refer
6. Anti-emetics – due to antagonism of dopaminergic NT
- For severe and unresponsive to NSAID/triptans
- Prochloroperazine
- Metoclopramide
7. Behavioral: adeq OFI, regular exercise, not skipping
meals, adeq 8-9h sleep, avoid caffeine
What is the SHARED MODEL of care: Lifestyle changes
Sleep hygiene
Hydration: increase water intake (6 urinations/day);limit caffeine; avoid energy drinks and sugary drinks
Headache diary- monitor headaches, response to treatment and identify triggers
Avoidance of triggers (identify, prevent and avoid) stress, warm -climate; video games
Regular aerobic exercise/activity; outdoor, face to face, socialize, limit screen time
Eating healthy: no skipped meals, food triggers (MSG, caffeine, alcohol, cured meats, peanuts, aged cheese
Downtime-stress management: relaxation; CBT, mindfulness; biofeedback
Preventive treatment for migraine
Preventive tx
- For frequent >1/week
- >1 disabling headache/mo
- Missing school, home, or social activities
- CI to or overuse of acute tx
- Uncommon conditions: hemiplegic migraine, basilar
migraine, prolonged aura
- pedMIDAS score >20
o pediatric migraine disability assessment
(pedMIDAS): self-administered
questionnaire to assess migraine disability
in pedia and adol
- Goal:
o To reduce freq of migraine (1-2 or fewer per
mo)
o To reduce disability PedMIDAS <10
1. Flunarazine – only 1 that demonstrates effectiveness
- 5mg OD, inc after 10 mos to 10mg OD, with a month
off the drug 14-6 mos
2. Amitriptylline – 1mg/kd OD, SE: sleepiness,
anticholinergic activity
3. Topiramate: 50mg BID
4. Valproic acid, beta blockers (Propanolol 2-4 mkd)
What are the RED FLAGS of headache?
Red Flags of Headache (SNOOPY)
- Systemic s/sx: fever, weight loss, rash, meningeal signs,
neurocutaneous lesions, malignancy
- Neurologic s/sx: hemiparesis, papilledema, hemisensory
loss, diplopia, visual changes, dysarthria, sz,
ataxia, cognitive changes, hx of head injury
- Onset: sudden, “worst headache of life” (thunderclap),
explosive onset; early, morning pattern or awakening
with headache
- Occipital: location
- P7: pattern change, progressions of existing headache,
previous headache hx, precipitated by Valsalva,
postural, pregnancy (change in quality, frequency,
location, steadily worsening pattern), post-traumatic
- Younger age group
* Escalating/progressive frequency or intensity of
headaches over several weeks (<4 months)in a child
less than 12 yrs or specially in less than 7 yrs of age
* A change of frequency and intensity of headache
patterns in young children
* Fever is not a component associated with migraine in
children of any age
* Headaches accompanied by seizures
* Altered sensorium may be associated with certain
migraine headaches but is not the norm in children
* Sudden onset of severe headache unrelieved by rest
and analgesics
* Nocturnal/morning headache
What is tension headache?
Patho
- Activation of hyperexcitable peripheral afferent
neurons from head and neck ms, abN central pain
processing and sensitivity
CM:
1. Bilateral with a pressing and tightening quality, mid to
moderate, nonthrobbing, constant pressure
2. Not associated with nausea or vomiting
3. not worsened by light or sound
4. pericranial muscle tenderness
5. assoc with/aggravated by psychological stress
6. frequency varies:
a. infrequent: <12x/y
b. frequent: 1-15x
c. chronic: >15/mo
7. duration: 30min-7d
Mgt
1. NSAID – ibuprofen, paracetamol
2. Amitriptyline – most evidence for effective prevention
3. Behavioral tx
What is brain tumor?
CH 497: BRAIN TUMOR
- Most common solid tumor in children
- 2nd most common CA after leukemias
- 0-14 yo: pilocytic astrocytoma, medulloblastoma
- 5-19yo: pituitary tumors and astrocytoma
- <1 yo, >10yo: supratentorial tumors
- >1-10yo: infratentorial tumors
- Most tumors in children are low grade gliomas (not
glioblastoma multiforme)
What is the pathophysiology of brain tumor?
Patho
- Originate from neural elements within the brain or a
metastatic spread of distant cancers –> inc ICP –>
compensatory mechanism –> reduction of volume of
blood and CSF
What are the clinical manifestations?
CM:
Related to CSF obstruction –> inc ICP, focal brain dysfunction
Infratentorial tumors:
1. Classic triad: headache, nausea, vomiting
2. Papilledema, BOV, nystagmus, diplopia
3. Disorders of equilibrium, gait, coordination
Supratentorial tumors:
1. Lateralized deficits, focal motor weakness, focal
sensory changes, language disorders, focal sz, reflex
asymmetry
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