Headache

Question 1

What are the three main groups of headaches in children?

Answer 1

Tension, migraine, and organic.

Question 2

What is the most common type of headache in children?

Answer 2

Tension, followed by migraine.

Question 3

List 5 serious causes of headache.

Answer 3

Infection, tumor, intracranial hemorrhage, CO poisoning, and hypertensive encephalopathy.

Question 4

What is the typical pattern of symptoms seen in patients with tension headaches?

Answer 4

The headaches are infrequent in the morning hours and typically become more severe as the day progresses. They present as a pressing, dull, persistent tightness, often described as a band around the head.

Question 5

What are three general causes of organic headaches?

Answer 5

Structural abnormalities, metabolic diseases, and infectious etiologies.

Question 6

What is the preferred imaging modality for patients suspected of having an organic headache?

Answer 6

MRI is the preferred imaging modality, but CT may be used if MRI is unavailable.

Question 7

What medications are associated with the development of pseudotumor cerebri in adolescents?

Answer 7

Doxycycline, tetracycline, and vitamin A (when it causes hypervitaminosis, such as in patients using retinoic acid for treatment of acne).

Question 8

What condition should be considered in an adolescent taking doxycycline or tetracycline for treatment of their acne who then presents with new headaches?

Answer 8

Pseudotumor cerebri

Question 9

List 15 warning signs of organic headaches.

Answer 9

Nocturnal awakening from headache; absence of family history of migraine; vomiting (especially early morning/upon arising); papilledema; confusion; abnormal neuro exam; growth abnormalities; nuchal rigidity; headache worsened by cough, micturition, or defecation; recurrent, localized headache; persistent vomiting; progressive increase in headache frequency or severity; lethargy; personality change; pulsatile tinnitus.

Question 10

Describe the typical presentation of cluster headaches.

Answer 10

The pain is strictly unilateral, severe, and is supraorbital, retroorbital, or temporal in location. It peaks quickly (within 5-10 minutes) and resolves in 1-2 hours. Patients may have associated ipsilateral autonomic symptoms (ptosis, miosis, lacrimation, eye redness, rhinorrhea, or congestion).

Question 11

Describe the age and gender distribution of cluster headaches.

Answer 11

Cluster headaches are rare in children < 10 years of age, but become increasingly common between 10 and 20 years of age. Boys are affected much more commonly than girls (3:1 to 4:1).

Question 12

What is the best treatment for acute symptoms of cluster headaches?

Answer 12

Oxygen. Ihalation of oxygen at 6L/min for 15 minutes is usually rapidly abortive.

Question 13

What is the drug of choice for prophylaxis against cluster headaches?

Answer 13

Verapamil

Question 14

What is the definition of a chronic headache?

Answer 14

Chronic headache is defined as headache that occurs > 15 days a month for >3 months and is not due to organic pathology.

Question 15

What is the diagnostic criteria for migraine without aura in children?

Answer 15

At least 5 attacks that: last between 2 and 72 hours; include at least two of the following (bilateral or unilateral location, pulsating, moderate-to-severe pain, and made worse with activity); and have at least one associated symptom (nausea/vomiting or photophobia/phonophobia).

Question 16

What is the diagnostic criteria for migraine with aura in children?

Answer 16

At least 2 attacks with the following features (gradual development of autonomic aura, aura that is fully reversible, aura present <1 hour, or headache within one hour of aura); one or more fully reversible aura symptoms (visual, sensory, speech, motor, brainstem, or retinal); and at least two of the following characteristics (at least one aura symptom spreads gradually over ≥5 minutes and/or ≥2 symptoms occur in succession; each individual aura symptom lasts 5-60 minutes; at least one aura symptom is unilateral; or the aura is accompanied, or followed within 60 minutes, by headache).

Question 17

How do basilar artery migraines classically present?

Answer 17

They occur more commonly in adolescent girls and present with vertigo, syncope, and dysarthria. Some also have visual alterations and loss of consciousness.

Question 18

How do hemiplegic migraines classically present?

Answer 18

The child has weakness on one side of the body with or without aphasia which can last hours to days.

Question 19

How does ophthalmoplegic migraine classically present?

Answer 19

This presents as an abnormality of eye movements, usually CN3. CN 4 and 6 are less commonly affected.

Question 20

How does confusional migraine classically present?

Answer 20

Patients present in a profoundly confused state that lasts for hours.

Question 21

What three drugs are used as abortive therapy for migraines in children and adolescents?

Answer 21

Almotriptan is approved for migraine pain in 12-17 year olds and rizatriptan is approved for children 6-17 years of age. Nasal sumatriptan is recommended for use in adolescents >18 years of age.

Question 22

Which 6 drugs are used for prophylaxis against migraines in children and adolescents?

Answer 22

Topiramate is approved for use in patients 12-17 years of age. Most data is anecdotal, but other frequently used agents include cyproheptadine, valproate, calcium channel blockers, propranolol, and amitriptyline.

Question 23

In what (17) situations would it be appropriate to order CT or MRI for evaluation of headache in a child?

Answer 23

Occipital headaches (rare in children, usually have a structural cause); unexplained academic decline or behavioral changes; abnormal neuro exam; fall-off in growth; headache that awakens the child from sleep; early morning headaches which increase in frequency and severity over time; headache with focal seizure; papilledema; migraine headache, followed by seizure; headache with vomiting in the absence of a family history of migraine; cluster headaches; any child < 3 years old with chief complaint of headache; brief coughing episode resulting in headache; increasing “crescendo” headaches; persistent focal headaches; increased head circumference; increase in severity of headache with Valsalva maneuver.