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Flashcards in Paeds: Headaches Deck (54):
1

General overview

Children with headache are commonly referred to general paediatricians.
- Over 90% will have chronic childhood headache, with no identifiable physical cause
- Some have migraine
Malignant brain tumours

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Types

Primary
Secondary
Other

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Malignant brain tumours

tumours obstructing CSF flow, causing hydrocephalus and consequent headaches are less common. These are almost always associated with focal signs on examination or a suggestive history, if present for more than 6 wks

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Primary headaches

Four main groups:
1. Migraine
2. Tension-type headache
3. Cluster headache (and other trigeminal autonomic cephalalgias)
Other such as cough or exceptional headache

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Secondary headaches

Symptomatic of some underlying pathology e.g raised intracranial pressure and space-occupying lesions
- Head and/or neck trauma
- Cranial or cervical vascular disorders – vascular malformation or intracranial haemorrhage
- Non-vascular intracranial disorder – raised ICP or IIH
- A substance or its withdrawal – alcohol, solvent or drug abuse
- Infection – meningitis or encephalitis
- Disorder of homeostasis – hypercapnia or hypertension
- Disorder of facial or cranial structures – acute sinusitis
Psychiatric disorder

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Crnaial neuralgias. Central and primary facial pain and other headaches

Trigeminal and other cranial neuralgias and other headaches including root pain from herpes zoster

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Primary headaches due to

primary malfunction of neurones

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Chronic, tension type headache

This form of headache is:
- Regular
- Often frontal or band like
Not associated with vomiting, paraesthesia, visual disturbance, or abnormality on examination (including BP)

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Chronic, tension type headache Chronic, tension type headache
History

Severe enough to take time off school, but with few objective signs of pain
Exclude signs of migraine, raised ICP, stresses
Chronic if there for 6wks +

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Chronic, tension type headache Investigation

Reassurance with thorough hx and exam
If inappropriate CT or MRI

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Chronic, tension type headache Treatment

Reassurance
Suggest analgesia (but may not help)
Continue to do normal daily activities
“ I can’t take away the headache, but the more normal things you do and the fewer drugs you take , the less you will notice the pain”.

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Migraine without aura
Presentation

- 90% of migraine
Episodes may last 1-72h; the headache is commonly bilateral but may be unilateral.

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Symptoms of migraine without aura

- Pulsatile, over temporal or frontal area and it is often accompanied by unpleasant gastrointestinal disturbance such as nausea and vomiting and abdo pain
- Photophobia or phonophobia (sensitivity to sounds)
Aggravated by physical activity

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Migraine with aura: Epi

Accounts for 10% of migraine

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Migraine with aura:
Presentation

- Preceded by an aura (visual sensory or motor), although the aura may occur without a headache.
Rarely unilateral sensory or motor symptoms

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Migraine with aura: Features are

The absence of problems between episodes and the frequent presence of premonitoring symptoms (tiredness, difficulty concentrating, autonomic features

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Migraine with aura: The most common aura comprises visual disturbance, which may include:

- Negative phenomena, such as hemianopia (loss of half the visual field) or scotoma (small areas of visual loss)
Positive phenomena such as fortification spectra (seeing zigzag lines)

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Migraine with aura: Course

Episodes usually last for a few hours during which the children often prefer to lie down in a quiet, dark place.

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Migraine with aura: Pathophysiology

Both tension type and migraine may overlap and result from primary neuronal dysfunction, including channelopathies, with vascular phenomena as secondary events.

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Migraine with aura: Family history

Genetic predisposition, with first- and second-degree relatives often also affected.

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Migraine with aura: Triggers

- Disturbance of inherent biorhythms, such as late nights or early rises, stress or winding down after stress at home or school.
- Certain foods e.g. cheese, chocolate and caffeine, are only rarely a reliable trigger
Girls: menstruation and the oral contraceptive pill

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Uncommon forms of migraine:

1. Familial
Sporadic 2. hemiplegic migraine
3. Basilar-type migraine
4. Periodic syndromes

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Familial

Linked to a calcium channel defect, dominantly inherited

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Basilar-type migraine

Vomiting with nystagmus and/or cerebellar signs

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Periodic syndromes description and types

Often precursors of migraine
1. cyclical vomiting
2. Abdominal migraine
3.Benign paroxysmal vertigo in childhood

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Cyclical vomiting

Recurrent stereotyped episodes of vomiting and intense nausea associated with pallow and lethargy. The child is well in between

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Abdominal migraine

An idiopathic recurrent disorder characterised by episode midline abdominal pain in bouts lasting 1-72hrs. Pain is moderate to severe in intensity and associated with vasomotor symptoms, nausea and vomiting. The child is well between episodes

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Benign paroxysmal vertigo of childhood

A heterogenous disorder characterised by recurrent brief episodes of vertigo occurring without warning and resolving spontaneously in otherwise health children. Between episodes, neurological examination, audiometric and vestibular function stets are normal.

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Raised ICP and space-occupying lesions: Characteristic features of S-O-L

Worse when lying down and morning vomiting
May cause night-time walking

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Raised ICP and space-occupying lesions: Other features

- Visual field defects – from lesions pressing on the optic pathways e.g. craniopharyngioma (a pituitary tumour)
- Cranial nerve abnormalities causinMay be change in mood
Personality or educational performance

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Raised ICP and space-occupying lesions: Cranial nerve abnormalities

- Diplopia
- New-onset squint or facial nerve palsy
- The VIth (abducens) cranial nerve has a long intracranial course and is often affected when there is raised pressure, resulting in a squint with diplopia and inability to abduct the eye beyond the midline.
- Abnormal gait
- Torticollis (tilting of the head)
- Growth failure e.g. craniopharyngioma or hypothalamic lesion
- Papilloedema – a late feature
Cranial bruits – may be heard in arteriovenous malformations but these lesions are rare.

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Raised ICP and space-occupying lesions: Abducens palsy

- It is a false localising sin
Other nerves are affected depending on the site of lesion e.g. pontine lesions may affect the VIIth (facial) cranial nerve and cause a facial nerve palsy

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Raised ICP and space-occupying lesions:
Management

- Thorough History and examination with detailed explanation and advice.
- Imaging is unnecessary in the absence of any red flag features.
- Informed that recurrent headaches are common
- Most good and bad spells, with periods of months or even years in between the bad spells, and that they cause no longterm harm.
Give information

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Raised ICP and space-occupying lesions:
Rescue treatments

- Analgesia: paracetamol and NSAIDS, taken as early as possible in an individual troublesome episode
- Anti-emetics – provhlorperazine and metoclopramide
Serotonin (5-HT1) agonists e.g. sumitriptan. A nasal preparation of this is licensed for use in children over 12 years of age.

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Associated with either or both of the following:

1. Abnormal examination, heel-toe walking, finger-nose co-ordination, eye movements and fundi (i.e. papilloedema)
Severe short history: vomiting, morning headaches, visual disturbance

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Clinically, the main concern is a

Mass obstructing CSF flow, particularly a malignant posterior fossa tumour.

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Investigation

- MRI superior, but CT head is performed if MRI not immediately available.
- ICP can be raised without abnormality evident on CT scan
If indication about thrombosis: of a cerebral sinus = MRI and MRV are recommended.

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Idiopathic intracranial hypertension (IIH): Definition

IIH or benign IH or pseudotumour cerebri typically is associated with obesity, female sex and adolescence.

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Idiopathic intracranial hypertension (IIH):
Secondary causes

- Drugs
- Systemic disease
- Endocrine changes
Head injury

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Idiopathic intracranial hypertension (IIH):
Drugs

- Steroid withdrawal
- Vitamin A
- Thyroid replacement
- Oral contraceptive pills
Phenothiazines

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Idiopathic intracranial hypertension (IIH): Systemic disease

- Iron deficiency
- Guillian-Barre syndrome
Systemic lupus erythematosus

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Idiopathic intracranial hypertension (IIH): Endocrine changes

- Adrenal failure
- Hyperthyroidism
- Hypoparathyroidism
- Menarche
- Pregnancy
Obesity

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Idiopathic intracranial hypertension (IIH): History

- Early monrning headache blurred or double vision
Vomiting

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Idiopathic intracranial hypertension (IIH): Exam

- General: check BP
- Neurology: there may be ataxia
Eyes: papilloedema; scortoma on visual field testing

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Idiopathic intracranial hypertension (IIH): Investigations

- Imaging: normal
Lumbar puncture: raised ICP (>20cm CSF); normal CSF cell count, protein and glucose

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Idiopathic intracranial hypertension (IIH): Management

- Weight loss in obese
- Try and remove causal medication
- Diuretics
- Steroids
- Monitoring of eyes and visual fields
Serial lumbar puncture or surgical intervention

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Idiopathic intracranial hypertension (IIH): Diuretics

To reduce CSF formation (e.g. acetazolamide, fureosemide)

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Idiopathic intracranial hypertension (IIH): Steroids

May be effective, but can cause rebound problems when withdrawn

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Idiopathic intracranial hypertension (IIH): Monitoring of eyes and visual fields

Most patients without visual deficit do well, but come patients with eye problems may deteriorate.

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Red Flags:

1. Headache – worse lying down or with coughing and straining
2. Headache: wakes up child (different from headache on awakening, not uncommon in migraine)
3. Associated confusion, and/or morning or persistent nausea and vomiting
4. Recent change in personality, behaviour or educational performance

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Other symptoms to be aware of

1. Growth Failure
2. Visual field defects – craniopharyngioma
3. Squint
4. Cranial nerve abnormality
5. Torticollis
6. Abnormal coordination – for cerebellar lesions
7. Gait – upper motor neurone or cerebellar signs
8. Fundi – papilloedema
9. Bradycardia
10. Cranial bruits – arteriovenous malformation

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Other physical signs:

- Visual acuity: for refractive errors
- Sinus tenderness – for sinusitis
- Pain on chewing – temporomandibular joint malocclusion
- Blood pressure – for hypertension

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Prophylactic agents:
Where headaches are frequent and intrusive:

- Pizotifen (5-HT antagonist) – can cause weight gain and sleepiness
- Beta-blockers – propranolol
- Sodium channel blockers – valproate or topiramate

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Psychosocial support:

- Psychological support – is it required to ameliorate a particular stressor e.g. bullying, anxiety over exams or illness in friends or family?
- Relaxation and other self-regulating techniques

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