Paediatric neurology Flashcards
(37 cards)
What is the epidemiology of headache disorders?
In about 40% children by age 7, 75% of children by age 15
What are the different types of headache patterns and which ones are investigated?
- Isolated acute (investigated)
- Recurrent acute
- Chronic progressive (investigated)
- Chronic non-progressive
What should be asked in the history of a child with a headache disorder?
- Is there more than 1 type of headache?
- Typical episode:
□ Any warning?
□ Location?
® Headaches located at the back of the head are more concerning
□ Severity?
□ Duration?
□ Frequency?
What examination should be done on a child with headache disorder?
- Growth parameters, OFC, BP
□ The head growing too fast may mean excessive CSF and hydrocephalus
□ If the child isn’t growing well then it could be a indication of a brain tumour - Sinuses, teeth, visual acuity
- Fundoscopy
- Visual fields (craniopharyngioma)
- Cranial bruit
□ Put a stethoscope on a child’s temporal area and listen for bruits - Focal neurological signs
- Cognitive and emotional status
What is a primary headache?
Tension headache and migraine
What are the pointers to childhood migraine?
- Associated abdominal pain, nausea, vomiting
- Focal symptoms/ signs before, during, after attack: Visual disturbance, paraesthesia, weakness
- ‘Pallor’
- Aggravated by bright light/ noise
- Relation to fatigue/ stress
- Helped by sleep/ rest/ dark, quiet room
- Family history often positive
- Hemicranial pain
- Throbbing/ pulsatile
What are the pointers to tension headache in children?
- Diffuse symmetrical
- Band like distribution
- Present most of the time but there may be symptom free periods
- “constant ache”
True or false: It is rare to have mixed migraine and tension type headache
False: they are common
What are the pointers to raised intercranial pressure in children?
- Aggravated by activities that raise ICP e.g. Coughing, straining at stool, bending
- Woken from sleep with headache
What are the pointers to analgesic overuse headache in children?
- Headache is back before allowed to use another dose
- Paracetamol/ NSAIDs
- Particular problem with compound analgesics e.g. Cocodamol
What are the indications for neuroimmaging?
- Features of cerebellar dysfunction
- Features of raised intracranial pressure
- New focal neurological deficit e.g. new squint
- Seizures, esp. focal
- Personality change
- Unexplained deterioration of school work
What is the management of migraine in children?
□ Acute attack: effective pain relief, triptans
□ Preventative (at least 1/week): Pizotifen, Propranolol, Amitriptyline, Topiramate, Valproate
What is the management of tension type headache in children?
□ Aim at reassurance: no sinister cause □ Multidisciplinary management □ Attention to underlying chronic physical, psychological or emotional problems □ Acute attacks: simple analgesia □ Prevention: Amitriptyline □ Discourage analgesics in chronic TTH
What is a seizure/ fit?
Any sudden attack from whatever cause
What is syncope?
Faint (a neuro-cardiogenic mechanism)
What is a convulsion?
Seizure where there is prominent motor activity
What is an epileptic siezure?
- An abnormal excessive hyper synchronous discharge from a group of (cortical) neurons
- It may have clinical manifestations
- Paroxysmal change in motor, sensory or cognitive function
- Depends on seizure’s location, degree of anatomical spread over cortex, duration
What is epilepsy?
- A tendency to recurrent, unprovoked (spontaneous) epileptic seizures
- A question that must be answered clinically, with recourse to EEG only for supportive evidence
- A seizure is not necessarily epileptic
- Consequences of misdiagnosis of epilepsy can be serious
What are the mechanisms of an epileptic fit?
□ Chemically triggered by:
® Decreased inhibition (gama-amino-butyric acid, GABA)
® Excessive excitation (glutamate and aspartate)
® Excessive influx of Na and Ca ions
□ Chemical stimulation produces an electrical current
□ Summation of a multitude of electrical potentials results in depolarization of many neurons which can lead to seizures, can be recorded from surface electrodes (Electroencephalogram)
What is the stepwise approach to diagnosing epilepsy?
□ Is the paroxysmal event epileptic in nature?
□ Is it epilepsy?
□ What seizure types are occurring?
□ What is the epilepsy syndrome?
□ What is the aetiology?
□ What are the social and educational effects on the child?
What is the role of EEG in diagnosing epilepsy?
® An interictal EEG has limited value in deciding when the individual has epilepsy
® Sensitivity of first routine interictal EEG: 30- 60%
® Problematic false positive rates: paroxysmal activity seen in 30%, frankly epileptiform activity in 5% of normal children
® Useful in identifying seizure types, seizure syndrome and aetiology
How is epilepsy dianosed in children?
® History
® Video recording of event
® ECG in convulsive seizures
◊ Can get epilepsy with arrhythmias
® Interictal/ ictal EEG
® MRI Brain: to determine aetiology e.g. Brain malformations/ brain damage
® Genetics: idiopathic epilepsies are mostly familial; also single gene disorders e.g. Tuberous sclerosis
® Metabolic tests: esp. if associated with developmental delay/ regression
What should be considered when thinking about giving anti-epileptc drugs to children?
- Anti-epileptic drugs (AED) should only be considered if diagnosis is clear even if this means delaying treatment
- Role of AED is to control seizures, not cure the epilepsy
- Start with one AED: slow upward titration until side-effects manifest or drug is considered to be inefficient
- Age, gender, type of seizures and epilepsy should be considered in selecting AEDs
- S/Es: CNS related can be detrimental; Drowsiness, effect on learning, cognition and behavioural
What are the antiepiletic drugs (and other therapies) that are used in children?
□ Sodium Valproate: first line for generalised epilepsies (not in girls- recent MHRA advice)
□ Carbamazepine: first line for focal epilepsies
□ Several new AEDs with more tolerability and fewer side effects: Levatiracetam, Lamotrigine, Perampanel
□ Other therapies: steroids, immunoglobulins and ketogenic diet (mostly for resistant epilepsies), surgical procedures
