CONTINUITY LECTURE SAMATHA MADHAVARAPU PGY -1. EPIDEMIOLOGY Significant health problem for children and adolescents. Up to 75% of children report having
EPIDEMIOLOGY Significant health problem for children and
adolescents. Up to 75% of children report having a significant
headache by the time they are 15 years of age 10.6% of children
between 5 and 15 years had migraine
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Meta-analysis of pediatric headache 3-7 Years : (1.2% to 3.2%
)Slightly male predominance 7-11 Yrs : 411% Equal male and female
predominance. 11- 15 years of age: 1823% Female predominance 15 19
Yrs : 28% had migraine, Females, migraine without aura common 81%
of adolescents with migraine had a positive family history.
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TTHs have been less well studied than migraine Migraine has a
genetic component Degree of inheritance as high as 90% in first- or
second-degree relatives TTHs are generally considered mild
recurrent headaches (previously called muscle contraction headache,
idiopathic headache, and tension headache Impact of headaches 1989
National Health Interview Survey found that within a 2-week period,
975,000 children had a migraine, resulting in 164,454 missed school
days.
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International Classification of Headache Disorders (ICHD-II).
Primary Headaches Secondary Headaches Directly attributed to a
neurologic basis Migraine Tension-type headaches (TTHs) Cluster
headaches Other primary neuralgias Attributed to a specific non-
neurologic cause. Infectious Vascular Traumatic Toxic Including
medications and overuse of medications Mass lesion
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Evaluation After the detailed history and medical examination,
it should be possible to determine whether the patient has a
primary or secondary headache The first step in evaluating a child
with headache is to rule out secondary causes
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Detailed Headache History Length of time the child has had
headaches Severity Quality :Throbbing, pulsating, tightness,
pressure, squeezing, sharp, stabbing, dull Location :frontal,
temporal, occipital, unilateral, bilateral Duration : number of
minutes, hours, or days Frequency : number per month, time interval
between headaches The effect on the childs quality of life and
disability Any aura before headaches Presence of Nausea/
vomitting
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History contd Time of onset: specific time of day, night-time
waking, relationship to particular activity/ menses Precipitating
factors: foods, odors/ perfumes, stressors Ameliorating factors:
sleep, exercise, quiet, dark room Associated factors: photophobia,
phonophobia Lifestyle factors: sleep pattern, exercise; diet:
caffeine intake, chocolate, aged cheeses, processed meats,
monosodium glutamate, nuts, and pickles Personality change: crying,
rocking, holding head, decreased activity/eating in younger
children; withdrawal in older children What does the
child/adolescent think is causing the headache? Prior treatment:
response to past treatment, frequency of use of over-the-counter or
prescription medications, use of herbs, vitamins, supplements, or
alternative therapies Activities; changes in school attendance or
performance; smoking, alcohol, or other substance abuse Detailed
review of systems
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History contd Medical History : trauma, infection, allergies,
ventriculo-peritoneal (VP) shunt placement, epilepsy, atopic
disorders, diabetes mellitus, depression or other psychiatric
disorders Family History : headaches in first- and second- degree
relatives Social History : Changes or stressors in the home,
school, or outside the home or school should be obtained
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Physical Exam Conducting a physical examination is important,
with an emphasis on the neurologic examination. Include a thorough
search for potential sources of secondary headache. Increased
intracranial pressure Sinusitis Dental disease Abnormalities of the
cervical spine Temporomandibular joint disorders
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Secondary headache causes Head or neck trauma Cranial or
cervical vascular disorder Nonvascular intracranial disorder
High-pressure headaches Low-pressure headaches Substance use/abuse
or withdrawal Includes medication overuse headaches Infection Brain
abscess Meningitis Encephalitis Disorders of homeostasis or facial
pain extending from Cranium Neck Eyes Ears Nose Sinuses Teeth Mouth
Psychiatric disorders
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MIGRAINE Migraine without aura, previously called common
migraine or hemicrania simplex Recurrent headache disorder Attacks
last 472 hours. Typical characteristics More often bilateral,
orbital, or frontotemporal, Pulsating quality Moderate or severe
intensity Aggravation by routine physical activity Association with
nausea, photophobia, phonophobia, unexplained paroxysmal abdominal
pain GI symptoms 60-85% of migrainous children
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Phases of Migraine attack Premonitory phase or prodrome : may
precede the headache phase by up to 24 hours irritability, elation
or sadness, talkativeness or social withdrawal, an increase or
decrease in appetite, food craving or anorexia, water retention,
and/or sleep disturbances Aura: focal cerebral dysfunction that
immediately precedes or coincides with the headache onset Only
10-20% of children with migraine experience an aura
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Phases of Migraine Aura: precedes the headache by less than 30
minutes and lasts for 5-20 minutes Motor auras last longer Children
are often unaware or unable to describe pictorial cards The visual
aura is the most common form in children, blurred vision,
fortification spectra (zigzag lines), scotomata (field defects),
scintillations, black dots, kaleidoscopic patterns of various
colors, micropsia, macropsia (distortion of size), and
metamorphopsia ("Alice in Wonderland" syndrome). moving or changing
shapes
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other auras include attention loss, confusion, amnesia,
agitation, aphasia, ataxia, dizziness, vertigo, paraesthesia, or
hemiparesis. Actual headache phase : usually shorter in children,
30 min- 48hrs. less severe Postdrome : patient may feel either
elated and energized or exhausted and lethargic
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MIGRAINE Migraine with aura (classic migraine) Aura consists of
visual, sensory, or speech symptoms. Gradual development Duration 1
hour Complete reversibility In addition to the aura, the headache
will have symptoms of migraine without aura. Chronic migraine
Frequent headaches (15 times per month for the previous 3 months)
Presence of migraine features Cannot be attributed to a secondary
cause
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Status migrainosus: severe form of migraine. Headache
continuous for over 72 hours. Hydration imp for those with
vomiting. Iv dihydroergotamine/ valprote is treatment. Familial
hemiplegic migraine : autosomal dominant form of migraine with aura
prolonged hemiplegia accompanied by numbness, aphasia, and
confusion. precede, accompany, or follow the headache. headache is
usually contralateral to the hemiparesis
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Basilar migraine Subtype of migraine with aura. Occipital
headache. Disturbances in function originating from the brain stem,
occipital cortex, and cerebellum Ataxia Bilateral paresthesias
Deafness Decreased level of consciousness Diplopia Dizziness Drop
attacks Dysarthria Fluctuating low-tone hearing loss Tinnitus
Unilateral or bilateral vision loss Vertigo Weakness
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Cyclic vomiting syndrome Migraine-associated cyclic vomiting
syndrome (periodic syndrome) Recurrent periods of intense vomiting
separated by symptom-free intervals Rapid onset at night or in the
early morning. Nausea, anorexia, abd pain, pallor, headache,
photo/phonophobia. Begins when the patient is a toddler and
resolves in adolescence. family history of migraine Respond to
antimigraine drugs
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TTH s Generally considered mild recurrent headaches Many
features are the opposite of those of migraine. TTHs can be
subdivided based on frequency. Infrequent, episodic Frequent,
episodic Chronic Diffuse in location Having a pressing quality No
secondary causes are identified
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Cluster headache histamine headache severe and unilateral,
sudden onset typically are located at the temple and periorbital
region ipsilateral lacrimation, nasal congestion, conjunctival
injection, miosis, ptosis, and lid edema few moments to 2 hours
grouping of headaches, usually over a period of several weeks. at
least 5 attacks occurring from 1 every other day to 8 per day and
no other cause for the headache. Distribution - First and second
divisions of the trigeminal nerve
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Danger Signs and Symptoms of Life Threatening Conditions that
Can Present with a Headache History: No family history in presence
of other signs & symptoms Lack of response to medical therapy
Early morning pain, with/without headache Night time awakening with
pain Persistant vomiting Increased pain with coughing/bowel
movt/voiding Chronic progressive pain Worst headache that has ever
had Personality change (depression &migraine indicate temporal
lobe tumor)
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Physical exam Age
Prophylactic treatment Second component Started when headache
becomes frequent / disabling Goal: minimize the effect & number
of headaches Having >23 headaches per month typically warrants
treatment For all prophylactic medications, titrate doses slowly to
an effective level This may be a lengthy process (weeks, months)
Migraine preventives: flunarizine, gabapentin, riboflavin,
metoprolol.
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Antiepileptics Only divalproate sodium and topiramate are
currently approved for the prevention of migraines in adults; they
are not approved for children Divalproate: Has not been formally
approved for use in migraine in persons 50 severe
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A 16-year-old girl who is new to your practice complains of a
nearly constant headache for the past year. She describes the pain
as a band around her head that often is throbbing and is worse
during the middle of the day. She denies nausea or vomiting but
reports occasional fatigue. There is no family history of
headaches. She has missed more than 20 days of school this year
because of the headache, and she is struggling to maintain a C
average. She admits to hating school and does not participate in
extracurricular activities because she "doesn't like anything."
Findings on her physical examination, including complete neurologic
and funduscopic evaluation, are normal. Of the following, the BEST
next step in the management of this girl's headaches is to
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Of the following, the BEST next step in the management of this
girl's headaches is to A. advise her to keep a headache diary and
return in 2 months B. obtain a lumbar puncture C. obtain computed
tomography scan of the brain D. prescribe oral sumatriptan E. refer
her for psychosocial evaluation and counseling
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A 14-year-old girl who has a 1-year history of migraine
headaches presents to the emergency department with a severe
headache that she calls "the worst headache of my life. " The
headache occurred suddenly after she lifted a heavy box. Her mother
says that the girl has been holding her head stiffly. On physical
examination, she appears in severe pain and has meningismus. Other
findings on the physical examination are normal. Of the following,
the MOST appropriate initial course of action is
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Of the following, the MOST appropriate initial course of action
is A. emergent noncontrast head computed tomography scan B.
intravenous administration of ceftriaxone C. intravenous
administration of dihydroergotamine D. lumbar puncture E. oral
administration of sumatriptan
