Headaches

Question 1

The difference in presentation of headaches in younger children vs older children.

Answer 1

Younger children express pain differently than older children.
E.g. Younger children may present with crying, rocking, etcetera - While older children may present as fussy, not as active, crying, etcetera

Question 2

Most important factor(s) in assessing headaches

Answer 2

History!
Ask the child first, then confirm with parent
OLDCARTS
Patterns, such as HA diary

Question 3

Headache physical exam

Answer 3

Normal physical exam in primary headaches.
Secondary headaches usually also have normal physical exam, but potentially present with fever, nuchal rigidity, abnormal neurologic exam

Question 4

Red flags from headache HISTORY

Answer 4

Patients under age 3 years
Sickle-cell disease 
Immunosuppressed patients
Malignancy
Coagulopathy
Right-to-left-shunt
Cardiac pathologies
Head trauma

Question 5

Red flags on headache PHYSICAL EXAM

Answer 5

Abnormal neurologic exam (usually HA is secondary to another etiology. May present with ataxia, weakness, diplopia, abnormal EOM, nuchal rigidity)

Papilledema or retinal hemorrhages

Growth abnormalities (e.g. increased head circumference, short stature, obesity, abnormal puberty progression)

Signs of trauma

Question 6

General red flags in pediatric headaches

Answer 6

Wakes child up!!!
Thunderclap headache or “worst headache of my life”
Persistent N&V, AMS, 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

Question 7

Mnemonic for headache red flags

Answer 7

SNOOP - any of which prompts further investigation including brain imaging or MRI or CT

S - systemic symptoms, illness, or condition (eg pregnancy, CA, immunocompromised, fever)

N - neurologic symptoms or abnormal signs (eg AMS, confusion, papilledema, focal neurologic symptoms, seizures)

O - onset is new (particularly in age > 40) or sudden (thunderclap)

O - other associated conditions or features (e.g. trauma, drugs, toxins; headache awakens from sleep; worse with valsalva, exertion, or sex).

P - previous headache history is not consistent with new headaches. i.e. change in attack frequency, severity, or clinical features.

Question 8

Pediatric migraine onset - differences in age and gender

Answer 8

Onset is greater in males than females (generally before puberty)
Males tend to onset around age 7
Females tend to onset around age 10
At puberty, migraines affect more girls than boys (changes with puberty shifts to present more in girls)

Question 9

Signs and symptoms of migraines

Answer 9

Migraines:

• Recurrent episodes
• Last 2-72 hours when untreated
• Pain: Throbbing focal pain, moderate-to-severe intensity, worsens with activity (rapid motion, sneezing, straining)… remember that migraines are vasovagal!!
• Associated with nausea, vomiting, and abdominal pain [and photophobia]. Relief with sleep, dark and quiet room, etc.

Question 10

Stages of migraine without aura

Answer 10

1. Prodrome
2. Headache
3. Postdrome

Question 11

Characteristics of prodrome

Answer 11

24+ hours prior to onset of headache
Euphoria, irritability, social withdrawal
Food cravings, constipation, neck stiffness, increased yawning

Question 12

Characteristics of migraine headaches in toddlers

Answer 12

Episodic pallor, decreased activity, vomiting

Question 13

Characteristics of migraine headaches in children

Answer 13

Bifrontal, bitemporal, generalized - “It hurts all over”
May present as more global headache than the classic unilateral
May present with associated nausea, photophobia, and/or phonophonia

Question 14

Characteristics of migraine headaches in teens

Answer 14

More often unilateral than global
Gradual onset and severity
More classic presentation as it gets worse gradually
Mild-moderate: Dull, deep, steady pain
Severe: Throbbing, pulsatile

Question 15

Characteristics of postdrome

Answer 15

Exhaustion

Some patients report elation/euphoria

Question 16

When does aura usually develop with migraine and how long does it last?

Answer 16

IF the patient has aura, it will usually present 30 minutes prior to onset of HA.
Aura lasts 5-20 minutes

Question 17

Most common types/characteristics of aura

Answer 17

VISUAL - spots in vision, visual changes, scotoma (a partial loss of vision or a blind spot in an otherwise normal visual field)

Can have weakness, numbness, tingling, dysphagia instead of visual aura

Question 18

Less common types/characteristics of aura

Answer 18

SENSORY -
Unilateral tingling in limbs or face (including tongue, mouth), followed by numbness for up to 1 hour
Dysphasia
Motor weakness (incredibly rare)

Question 19

Nonpharmacologic management of migraines

Answer 19

Assess and avoid TRIGGERS - Headache diary

Dark, quiet room with prodrome begins

Question 20

Prescription/pharmacologic treatment for migraines.

Answer 20

NSAIDs/Acetaminophen for mild to moderate pain

Triptans for more severe migraines (e.g. sumatriptan)

Question 21

Cluster headaches - pediatric prevalence

Answer 21

Rare in children under age 10 years

Question 22

Characteristics of cluster headaches

Answer 22

Most common trigeminal autonomic cephalagia
Unilateral, frontal-periobital region
Pain: Severe
Duration: Less than 3 hours
Frequency: Recurrent over short time
Associated findings: Ipsilateral autonomic findings, such as lacrimation, rhinorrhea, ophthalmic injection, Horner syndrome

Question 23

Cluster headache treatment

Answer 23

Minimize source of stress
Avoid triggers
Address comorbid sleep problems
Nonpharmacologic treatments (start before Rx) - CBT, biofeedback
Rx treatments: Acetaminophen or NSAIDs (equal efficacy)

Question 24

When to initiate preventative treatment for cluster headaches

Answer 24

When the child has >4 headaches/month or headaches affect normal activities

Question 25

Signs and symptoms of tension headaches?

Answer 25

Pain: Diffuse across forehead; Non-throbbing Does not worsen with activity (different from migraine) Severity: Mild-to-moderate severity. Duration: Anywhere from half hour to 1 week Associated findings: May have nausea, photophobia, or phonophobia NOT associated with vomiting

Question 26

Treatment for tension-type headache (TTH)

Answer 26

Minimize stress Avoid triggers Address cormorbid sleep problems Nonpharmacologic treatments (start before Rx): CBT, biofeedback Rx treatment: Acetaminophen or NSAIDs (equal efficacy) Rx for FREQUENT or CHRONIC TTH - TCA (amitriptyline - rarely used with pediatrics), if OTC doesn't work

Question 27

Menstrual migraines - Criteria for diagnosis

Answer 27

Migraines that occur in close correlation with menses Defined as 2 days prior to 3 days after the initial bleed Occur with at least 2/3 of the individuals menstrual cycles As compared to migraines without meneses: More severe, longer duration, less responsive to treatment. These patients can also experience migraines outside of meneses Most menstrual migraines are without aura

Question 28

Menstrual migraines treatment

Answer 28

Same as non-menstural migraines: NSAIDs, APAP, triptans (severe). Preventative therapy Controversial use of estrogen-progestin therapies - must consider the risk of stroke. Not for migraine with aura (most menstrual migraines are without aura).

Question 29

What is pseudomotor cerebri?

Answer 29

AKA: Idiopathic intracranial hypertension Is a diagnosis of exclusion Has s/sx of increased ICP (>280 mmHG for oese or sedated child; >250 mmHg for nonobese, nonsedated child; Papilledema universally present in child with a closed fontanel) No other causes of intracranial hypertension evidence on neuroimaging!!`

Question 30

Clinical presentation of pseudomotor cerebri

Answer 30

Headache!! - Most often severe, rarely presents without Transient visual obscuration Intracranial noises (pulsatile tinnitus) Photospia Back pain Retrobulbar pain!!! - pain with eye movement in any direction. Might indicate vision loss, which can be permanent!! Diplopia Mostly occurs post-pubery, BMI greater than 28 (overweight, obese)

Question 31

Clinical characteristics and associated symptoms of pseudomotor cerebri headaches

Answer 31

Variable features - lateralized, throbbing, pulsadile, intermittent or persistent Often severe headache and associated with nausea and vomiting 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, and frontal headache

Question 32

Physical exam for pseudomotor cerebri

Answer 32

Papilledema - MOST consistent sign beyond infancy (fontanels close)!! Visual field loss Bulging fontanel with Macewen sign (drum like sound on palpation) CN exam - 6th nerve palsy (Esotropia may be present or elicited in testing of EOMs) Postural changes Gait assessment

Question 33

Diagnostics for pseudomotor cerebri

Answer 33

Urgent MRI to rule out other causes of increased ICP If nothing on MRI, perform LP (which will show normal CSF with high opening pressure) Pseudotumor cerebri is a diagnosis of exclusion!

Question 34

Management of pseudotumor cerebri

Answer 34

MRI and referral to neurology/neurosurgeon Lumbar puncture - can be therapeutic, allowing drainage in the dura to reduce the pressure Rx: Diamox, short-term corticosteroids, lasix Weight loss is helpful in reducing prevalence and s/sx If severe presentation or vision involvement - optic nerve sheath fenestration of CSF shunting

Question 35

Concussion symptoms

Answer 35

``` Headache Fatigue Dizziness, balance problems Poor memory Delayed speed of processing Light/noise sensitivity Irritability, crying Anxiety, depression Change in sleeping, nursing, eating patterns ```

Question 36

Physical exam of concussion

Answer 36

``` Fontanel / Head circumference Mental status Motor exam DTRs Sensory function Cerebellar exam Saccades (eye movement) ```

Question 37

What is saccades

Answer 37

Quick, simultaneous movement of both eyes between two phases of fixation in the same direction Is a sign of concussion

Question 38

Tools to evaluate concussion

Answer 38

ACE (Acute concussion evaluation) CAT3/SCAT3 (Sports concussion assessment tool 3) SAC (Standardized assessment of concussion) BESS (Balance error scoring system)

Question 39

Signs of concussion deterioration

Answer 39

``` Headache that worsens Seizures Focal neuro signs Lethargy Repeated vomiting (especially in AM) --- need a CT Slurred speech Can't recognize people or places Increased confusion, irritability, or excessive crying Weakness or numbness in arms or legs Neck pain/rigidity Extreme behavior change Loss of consciousness >30 seconds ```

Question 40

Concussion - neuroimaging vs. observation in patients under age 2 years

Answer 40

CT: suspected abuse, focal findings, fractures, lethargy, bulging fontanels, persistent emesis, seizures, prolonged LOC CT OR Observation: Self-limited vomiting, behavior changes, nonacute skull fracture, unwitnessed trauma/LOC OBSERVATION/No CT: No AMS, no scalp hematoma, no LOC >5 seconds, no fracture, normal behavior, no high risk injury (e.g. fall > 3 feet)

Question 41

Concussion - neuroimaging vs. observation in patients older than 2 years of age.

Answer 41

CT: focal findings, seizure, persistent AMS, lethargy, agitation, prolonged LOC CT OR Observation: Vomiting, headache, brief or questionable LOC OBSERVATION/No CT: No severe headache, no high risk injury, no vomiting, no basilar fracture, no LOC

Question 42

Management of concussions

Answer 42

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 - only after all s/sx are gone

Question 43

Signs and symptoms of postconcussion syndrome

Answer 43

``` Vague s/sx #1: Persistent headaches #2: Dizziness Nausea, memory impairment, poor attention, excessive crying, sleep changes, change in nursing or eating habits, easily upset/increased tantrums, sad or lethargic, lack of interest in favourite toys ```

Question 44

Treatment for post-concussion sydrome

Answer 44

CBT and PT Referrals - e.g. ENT for persistent vergio Consider MRI if s/sx worsen or is disabling Medications are supportive - APAP, motrin

Question 45

Long-term complications of post-concussion sydrome

Answer 45

Headaches - Migraine disorders (50% with concussion), Tension-type headache (TTH) (most common) Memory and learning problems

Question 46

Post-concussion - when to return to school?

Answer 46

Headache-free 24 hours Can read 30 minutes without headache Strict guideines! If headache occurs at school, go to the nurse or go home Auditory learner at first