Headaches Flashcards
(46 cards)
1
Q
Presentation of HAs in younger vs older kids
A
Younger kids express pain differently! (i.e. crying, rocking, etc)
Toddler – fussy, not as active, crying
2
Q
Most important factor in assessing HAs?
A
- History!
- Child first, confirm w/parents
- OLDCARTS
- Patterns (HA diary)
3
Q
HA PE
A
- Normal in primary HAs
- Usually normal in secondary HAs, but may have fever, nuchal rigidity, abnormal neuro exam
4
Q
Red flags on HA history
A
- · <3 years old
- · sickle-cell disease
- · immunosuppressed
- · malignancy
- · coagulopathy
- · right-to-left shunt cardiac pathologies
- · head trauma
5
Q
Red flags on HA PE
A
- Abnormal Neuro Exam
- This is 2ndary etiology
- Ataxia
- Weakness
- Diplopia
- Abnormal EOM
- Papilledema or retinal hemorrhages
- Growth abnormalities, i.e. increased head circumference, short stature, obesity, or abnormal pubertal progression
- Nuchal Rigidity
- Signs of trauma
- Cranial bruits
6
Q
Red flag HA characteristics
A
- Wakes child up!!!
- Thunderclap headache or “worst headache of my life”
- Persistent nausea/vomiting, altered mental status, ataxia
- Worse in recumbent position or by vasovagal causes
- Chronic progressive pattern
- Change in quality, severity, frequency, or pattern
- Occipital headache
- Recurrent and localized
- Duration < 6 months
- Doesn’t respond to medication
7
Q
Mnemonic for HA red flags
A
- Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy, immunocompromised state including HIV)
- Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, papilledema, focal neurologic symptoms or signs, meningismus, or seizures)
- Onset is new (particularly for age >40 years) or sudden (eg, “thunderclap”)
- Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual activity)
- Previous headache history with headache progression or change in attack frequency, severity, or clinical features
- Any of these findings should prompt further investigation, including brain imaging with MRI or CT.
8
Q
Migraine onset: age and gender
A
- Onset younger in boys (7 years old) than girls (10 years)
- At puberty, migraines affect more girls than boys
- Changes with puberty as it shifts to girls!
9
Q
S/S of migraines
A
- Pattern: recurrent episodes that last 2-72 hours if untreated
-
Pain: throbbing focal pain, moderate to severe intensity, worsens with activity (rapid motion, sneezing, straining)
- Migraines = Vasovagal!
- Associated with nausea, vomiting, abdominal pain, and relief with sleep (dark, quiet room)
10
Q
Stages of migraine w/o aura
A
Prodrome, HA, postdrome
11
Q
Characteristics of prodrome
A
- Euphoria, irritability, social w/drawal
- Food cravings, constipation, neck stiffness, increased yawning
- 24+ hours prior to onset of HA
12
Q
Characteristics of migraine HA in toddlers
A
Episodic pallor, decreased activity, vomiting
13
Q
Characteristics of migraine HA in children
A
Bifrontal, bitemporal, generalized w/N and photophobia/phonophobia
“hurts all over”
14
Q
Characteristics of migraine HA in teens
A
- More oftn unilateral than global, gradual onset & severity
- More classic presentation as it gets worse gradually
- Mild-moderate: dull, deep, steady pain
- Severe: throbbing, pulsatile
15
Q
Characteristics of postdrome
A
- Exhaustion
- Some people report elation/euphoria
16
Q
When does aura usually develop w/migraine and how long does it last?
A
If they have it, usually 30 minutes prior to onset of HA, lasting 5-20 minutes
17
Q
Most common characteristics of aura
A
VISUAL: spots in vision, scotoma, visual images
Can be weak, numbness, tingling, dysphagia instead of visual aura
18
Q
Less common types of aura
A
- Sensory: unilateral tingling in limbs or face (including mouth and tongue), followed by numbness for up to 1 hour
- Dysphasia
- Motor weakness (incredibly rare)
19
Q
Nonpharm mgmt. of migraines
A
- Headache diaries
- Assess triggers!
- Dark, quiet, room
- When prodrome happens, put them into a quite room
20
Q
Rx for migraines
A
NSAIDs/ Acetaminophen for mild to moderate, Triptans for more severe migraines
21
Q
Cluster HAs: age distribution
A
- rare in children < 10 years old
22
Q
Characteristics of cluster HAs
A
- most common trigeminal autonomic cephalagia
- Unilateral, frontal-periorbital region
- Pain: severe, l <3 hours, recurrent over short period of time
- Same-sided autonomic findings: lacrimation, rhinorrhea, opthalmic injection, Horner syndrome
23
Q
Cluster HA Tx
A
- Minimize sources of stress
- Avoid triggers
- Address cormorbid sleep problems
- Nonpharmlogical treatments: CBT, biofeedback
- Start with this before Rx
- Rx: Acetaminophen or NSAIDs (Equal efficacy)
24
Q
When to initiate preventive tx for cluster HAs
A
- when child has >4 headaches/month or headaches affect normal activities
25
S/S of tension HAs
* diffuse pain: across the forehead
* non-throbbing
* mild to moderate severity
* do not worsen with activity
* last anywhere from a half hour to 1 week
* May be associated with:
* nausea, photophobia, or phonophobia
* Not associated with vomiting
26
TTH Tx
* Minimize stress
* Avoid triggers
* Address cormorbid sleep problems
* Nonpharmlogical treatments: CBT, biofeedback
* Start with this before Rx
* Rx: Acetaminophen or NSAIDs
* Equal efficacy
* Rx for frequent or chronic TTH: tricyclic antidepressants (amitriptyline – rarely used with pediatrics) if OTC doesn’t work
27
Menstrual migraines: criteria for Dx
* Migraines that occur in close correlation with menses (defined as 2 days prior to 3 days after the initial bleed)
* Occur with at least ⅔ of the individuals menstrual cycles
* As compared to migraines without menses:
* **more severe**
* **longer duration**
* **less responsive to treatment**
Persons identified with this condition can also experience migraines outside of menses
28
Tx for menstrual migraines
* same as non-menstrual migraine:
* Abortive therapy: **NSAIDS, acetaminophen, triptans (severe)**
* Preventative therapy
* Controversial use of estrogen-progestin therapies
* \*consider risk of stroke
* not for with aura – most menstural migraines are without aura
29
What is pseudotumor cerebri?
* AKA Idiopathic intracranial hypertension (dx of exclusion). S/S of increased ICP.
* \>280 mm Hg for obese or sedated child
* \>250 mm Hg for nonobese, nonsedated child
* Papilledema universally present in child with a closed fontanel
* **no other cause of intracranial hypertension** evident on neuroimaging
30
Clinical presentation of pseudotumor cerebri
* **HA: most often severe, rare to present w/o**
* Transient visual obscurations
* Intracranial noises (pulsatile tinnitus)
* Photopsia
* Back pain
* **Retrobulbar pain**
* **Pain with movement of eye in any direction**
* **Might indicate vision loss! May be permanent**
* Diplopia
* Mostly post puberty, BMI greater than 28 – obese
31
Characteristics of pseudotumor cerebri HA
* Variable features
* Lateralized
* Throbbing
* Pulsatile
* Intermittent or persistent
* Often severe, associated N/V
* worse with postural changes
* When you lay down then sit up – fluid shift
* Or relief with vomiting because release in ICP
* Most commonly chronic, progressive, frontal
32
PE for pseudotumor cerebri
* **Papilledema: _most_ consistent sign beyond infancy**
* Visual field loss
* Bulging fontanel with Macewen sign (drum like sound at palpation)
* CN assessment: Sixth nerve palsy
* Esotropia may be present or elicited in testing of EOMs
* Postural changes
* Gait assessment
33
Diagnostics for pseudotumor cerebri
* Urgent MRI to r/o other causes of increased ICP
* Nothing on MRI? à LP
* CSF nl with high opening pressure.
Diagnosis of exclusion!
34
MGMT. of pseudotumor cerebri
* MRI and referral to neurology/neurosurgeon
* LP- can be therapeutic, allows drainage in the dura to reduce pressure (therapeutic)
* Diamox, short term corticosteroids, lasix
* Weight loss is helpful in reducing prevalence and s/s
* If severe/vision involvement: optic nerve sheath fenestration or CSF shunting
35
Concussion: Symptoms
* H/A
* Fatigue
* Dizziness, balance problems
* Poor memory
* Speed of processing
* Light/noise sensitivity
* Irritability, crying
* Anxiety, depression
* Change in sleep/nursing/eating patterns
36
Concussion on PE
* fontanel / HC
* Mental status
* Motor exam
* DTRs
* Sensory function
* Cerebellar exam
* Saccades
37
What is saccades?
Quick, simultaneous movement of both eyes between two phases of fixation in same direction
Sign of concussion
38
Tools to evaluate concussion
ACE: Acute Concussion Evaluation
CAT3, SAC, BESS
39
Signs of concussion deterioration
* H/A that worsens
* Seizures
* Focal nero signs
* Lethargy
* Repeated vomiting (especially in AM) à Need CT
* Slurred speech
* Can’t recognize people/ places
* Increasing confusion, irritability, or excessive crying
* Weakness/numbness in arms/legs
* Neck pain/ rigidity
* Extreme behavior change
* Loss of conscioussness \>30 seconds
40
Concussion: neuroimaging vs observation when \<2yo
* **CT:** suspect abuse, focal findings, fractures, lethargy, bulging fontanels, persistent emesis, seizures, prolonged LOC
* **CT or obs:** self-limeted vomiting, behavior change, nonacute skull fracture, unwitnessed trauma/loc
* **No CT**: No AMS, no scalp hematoma, no LOC \>5s, no fracture, nl behavior, no high risk injury (fall \>3ft)
41
Concussion: neuroimaging vs observation when 2+yo
* **CT**: focal findings, seizure, perisstent AMS, lethargy, agitation, prolonged LOC
* **CT** or obs: vomiting, HA, brief or ? LOC
* **No CT**: no severe HA, no high risk injury, no vomiting, no basilar fx, no LOC
42
Concussion Mgmt approaches
* Physical and cognitive rest
* Return to daily activities: gradually as improving, naps, good sleep
* Return to school: gradually, lower workload, breaks, no big exams, no gym
* Return to sports: all S/S gone
43
S/S post-concussion syndrome?
* Vague
* #1: persistent HA
* #2: dizziness
* nausea, memory impairment, poor attention, excessive crying, sleep changes, change in nursing or eating haits, easily upset/increased tantrums, sad or lethargic, lack of interest in fav toys
44
Tx for post concussion syndrome
* CBT & PT
* Referrals: e.g., ENT for persistent vertigo
* Consider MRI if worsens, dissables
* Meds: tylenol, motrin
45
ong term complications of post concussion syndrome
* Headaches: migraine Dos (50% w/concussion!), TTH (most common)
* Memory and learning problems
46
Post concussion: when to return to school?
* HA free 24h, can read 30 min w/o HA
* Strict guidelines! If HA, go to nurse or go home
* Auditory learner at first
