Pediatric Neurology Quick Talks

Headache
Michael Babcock
Summer 2013
Scenario

• 7 yo boy
• Headaches for 4 months
• Headaches last 90 minutes
• Grabs the front of his head when it hurts
• Has about 1 headache a week, vomits with some of the headaches
• Continues to do well in school, no vision complaints
Causes of headache

• Primary • Secondary
– Migraine – Medication overuse
– Tension-type (rebound)
– Cluster – head/neck trauma
– Paroxysmal hemicrania – Vascular disorder – SAH,
AVM, vasculitis, CSVT
– SUNCT
– High ICP / Low ICP
– Trigeminal neuralgia (not
common in kids) – Tumor
– Chronic daily headache – Infection
• CNS
• Other infections
History

• Headache – quality, severity, location, laterality, onset, time course –

episodic and similar or progressive/changing
• Associated symptoms – systemic symptoms, fever, personality changes,
seizures
• Preceding symptoms – aura, gradual/rapid onset
• Exacerbating features – migraines worse with activity; worse with laying
or nocturnal or with cough/straining – signs of elevated ICP; worse with
standing – signs of low ICP.
• Medical history – NF1, Sturge-weber, connective tissue disorder, Sickle
cell, immunocompromised.
Exam

• Vitals – fever, ICP signs

• Good neurologic exam
– ? Altered mental status
– Abnormal eye movements
– Visual field testing
– Fundoscopic exam
– Focal weakness
– UMN signs
– Abnormal gait
Papilledema (normal to severe)
 Work-up
• Imaging
– Trauma • CSF analysis
– Associated seizures – Pseudotumor (IIH)
– AMS • Accurate recording of pressure,
in lateral decub position must
– Abnormal neurologic exam
extend LE's.
– Historical features – thunderclap
– Meningitis
headache, persistently lateralized,
progressive course, shunt, change in • Meningismus
pattern/type, occipital headache • Fever
– Signs of elevated ICP • New seizures
– Considerations: • AMS
• no family history of migraine • immunocompromised
• < 1 month of headache – SAH
• Young age of onset • Thunderclap headache
– Prior to LP
Migraine

• Affects 7% of all children

• Causes $1-17 billion in lost productivity
• Accounts for 10 million physician visits/year in U.S.
Migraine Classification

• Pediatric migraine with aura

– At least 2 attacks fulfilling B.
– At least 3 of the following
• One or more fully reversible aura
symptom indicating focal
cortical and/or brainstem
dysfunction
• at least 1 aura developing
gradually over > 4 min or > 2
aura symptoms occurring in
succession
• No auras lasting > 60 minutes
• Headache no more than 60
minutes after aura
Migraine treatment – Life-style modification

• Sleep – don't vary by more than one hour on school/weekend nights

• Exercise – regular exercise, but over-exercise can cause headache
• Mealtimes – 3 meals daily, don't skip meals
• Hydration – carry water bottle – school excuse to carry and go to
bathroom
• Stress – stress reduction techniques
• Caffeine – moderation or stop
• Analgesic overuse
– Don't use OTC pain relievers more than two-three times weekly
– Opiates can also cause this
– To relieve headache – have to break cycle, stop medication, headache
worse for 2-3 weeks, then better.
Migraine Medications - Preventative

• Cyproheptadine – AAN PP – insufficient evidence – histamine and

serotonin antagonist with Ca-channel blocking properties; SE – weight-
gain and sedation. Can be OK for younger, non-overweight children.
• Beta-blockers – conflicting evidence. SE – asthma, DM, orthostatic
hypotension, depression, not good for athletes
• Amitryptaline (TCA's) – depressino/affective disorder often co-morbid
with migraines. SE – QT prolongation – get EKG, behavior change
• Ca-channel blockers – Verapamil – good for hemiplegic migraine
• AED's
– Topamax – SE – weight loss, cognitive change, sedation
– Depakote – SE – weight gain, PCOS, teratogenic; need CBC/LFT
monitoring
– Keppra – consider because low SE profile
– Gabapentin – SE – sedation
 Migraine Medications – Abortive
• Naproxen (Aleve) – 10-20mg/kg/d div Q8H. For patients over 30kg. Can give 1-2
tabs at onset, 1 more tab in 8 hours.
• Motrin
• Fioricet (acetaminophen/butalbital/caffeine) or fiorinal – good for rescue but risk of
dependance, overuse – probably best not to give outside ED.
• Anti-emetics – Phenergan, Reglan, Compazine – can give benadryl to help with
sleep/extrapyramidal effects
• Triptans – Sumatriptan (PO, SC, IN) – Adult oral PO dose is 25-100mg at onset,
max 200mg/day PO. No dosage recommendations for children in packet. SE--
heart – vasospasm, MI, arrhythmias, HTN, stroke, seizure, rebound headaches;
chest/jaw/neck pain.
• Ergots – nasal DHE (Migrinal nasal spray) – 1 squirt in each nostril – SE—chest
pain, nausea, cannot use within 24 hours of triptan
• In ED – hydration with NS, Magnesium, Depakote, Ketorolac if not medication
overuse, compazine, benadryl, steroid
References

• http://eyewiki.aao.org/Papilledema
• http://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.html
• AAN Practice parameter – migraines
• Maria, B. 2009. Current management in child neurology. People's medical
publishing house.