Headaches and Head Injuries in Children and Adolescents

Texas Children’s Hospital Advanced Practice Provider ConferenceFebruary 7, 2014

Deanna Duggan, MS, RN, CPNP-PC, PMHSHeadache ClinicBlue Bird Circle Clinic for Pediatric NeurologyTexas Children’s HospitalBaylor College of Medicine

Objectives1. Identify clinical presentation of

primary and secondary headaches2. Identify up to date recommendations for

management of secondary headaches attributed to head injury

3. Assimilate medical and psychological interventions

4. Enable the pediatric provider how to construct an individualized headache treatment plan

Overview

• Incidence and prevalence in the pediatric population

• Degrees of disability

• Types

• Accurate diagnosis is key

• International Headache Society Classification

www.ihs-classification.org/en

• Concussion vs. Traumatic Brain Injury

Examples of headache types described in ICHD-2

Part I: The Primary Headaches• Tension-type Headache• Migraine (with or without aura)• Cluster Headaches and other Trigeminal Autonomic Cephalalgias

Part II: The Secondary Headaches• Headache Attributed to Head or Neck Trauma

Acute Post-Traumatic HeadacheChronic Post-Traumatic HeadacheAcute Headache Attributed to Whiplash InjuryPost-craniotomy Headache

• Medication Overuse Headache• Cervicogenic Headache

Part III: Cranial Neuralgias, Primary and Central Causes of Facial Pain

Evaluate

• Characteristics of the headache and headache pattern

• Baseline headache• Is there resolution of symptoms in-between headaches?

• Consider other disorders or triggers• Mechanism of injury• Concussion: Describe symptoms reported immediately after injury and days subsequent to injury

• Is there a concussion history?• What makes the headache better or worse?• Physical and Neurological exam (including fundoscopy)

• Neuroimaging

Red Flags in the Diagnosis of Childhood Headaches

• Escalating frequency and/or severity of headaches over several weeks (under 4 months) in a child under the age of 12, and even more importantly under the age of 7

• A change of frequency and severity of headache patterns in young children

• Fever is not a component of migraine at any age, especially in children

• Headaches accompanied by seizures

• Sensory disturbance may occur in certain forms of migraine, however, neurological attention is warranted to determine appropriate assessment and intervention

Symptomatology

Post concussion symptom checklist

• Headache• Nausea/vomiting• Balance problems• Dizziness• Sensitivity to light• Blurred vision• Sensitivity to noise• Nervousness• Numbness/tingling• Feeling ‘slowed down’• Feeling like ‘in a fog’• Difficulty concentrating• Difficulty remembering• Neck pain• Fatigue/drowsiness• Difficulty sleeping• Sadness• Irritability

*Symptoms are subjective*- 38% of athletes reporting no symptoms may still demonstrate neurocognitive deficits (Broglio, 2008)

Define a concussion

• Symptoms that may occur after injury to the head include at least one of the following: Any period of loss of consciousness, any loss of memory for events immediately before or after injury, alteration in mental state at the time of injury and/or focal neurological deficits that may or may not be transient

• Symptoms that may persist after injury:1. loss of memory or AMS (dazed, disoriented, confused)2. physical symptoms (nausea, vomiting, dizziness, HA, tinnitus, blurred vision, sensory loss, sleep disturbance or extended periods of fatigue/lethargy)3. cognitive deficits (attention, concentration, language, memory, perception)

Examination1. Observe:

Aphasia or speech difficultyBehavior

2. Palpate: Head and neck for

painful/tender areas, swelling or crepitus

3. Assess:Neck ROM (active and passive)Neck strengthDermatomes and myotomes

4. Stress tests3 Cs: CognitionCoordinationCranial nerves

Cognitive Screening Tools

SCAT2SAC (sideline mental status tests)CNS Vital SignsCogSportHeadMinderImPACTSports as a Laboratory Assessment Model (SLAM)

Automated Neuropsychological Assessment Metrics

• Serial evaluations• Neuropsychological evaluation

What is cognitive “rest”?

• Safety Guidelines :1. Restrict physical activity until all symptoms COMPLETELY resolved2. Risk for “Second Impact Syndrome” (repeat concussion that occurs soon after initial concussion) - Result can be a rapid, catastrophic increase in pressure within the brain. Effects include physical paralysis, mental disabilities, and epilepsy. Death may occur approximately 50% of the time. 3. Plan for educational modifications specific to the patient per section 504 Other Health Impairment – Traumatic Brain Injury

* extended time to complete schoolwork or testing * testing in a separate room with decreased environmental stimulation

* extended time to walk in-between classrooms, have small frequent meals, carry a water bottle and liberal bathroom privileges * allow for the patient to stop any educational activity should severe headache or other neurological symptoms exacerbate. In such case, child should be excused immediately * partial attendance or homebound

Traumatic headache/Concussion treatment: Key factors• Symptom exacerbation following physical or cognitive activity is a sign that the brain’s dysfunctional neurometabolism is being pushed beyond tolerable limits

• In guiding recovery, management of neurometabolic demands on the brain is crucial

• Do not allow patients to exceed physiologic threshold:Pay attention to over-exertion

- physical - cognitive

• Concussion is most common concussion-related symptom

• Migraine a risk factor for concussion?

Management

• Drink adequate amounts (calculate daily maintenance) of non-caffeinated fluids daily. OK to include Gatorade, Propel or other electrolyte-infused beveragesMaintenance Fluid requirements per body weight in kilograms

• Eat 4 to 5 small, frequent meals including green, leafy vegetables (rich in vitamin B2 and coenzyme Q10)

• Maintain regular sleep cycle of at least 8 (may need 10) hours per night

• Avoid physical and cognitive strain. NO sports• Physical Therapy /Graduated Return to Play guidelines once patient is symptom free for at least 24 to 48 hours

1 – 10 kg 100 mL/kg

11 - 20 kg 1000 mL + 50 mL/kg for each kg > 10 kg

> 20 kg 1500mL+ 20 mL/kg for each kg > 20 kg

Management (continued)

• Abortive Medications1. NSAIDS (ibuprofen, naproxen, etodolac, ketorolac)2. Antiemetics including Phenergan, Zofran, Compazine or Reglan 3. Triptans (Axert, Maxalt, Zomig, Relpax, Imitrex)

4. DHE 5. Depakote6. Dexamethasone or Medrol Pak

• Other medications that might help: muscle relaxers (cyclobenzaprine, tizanidine)

Treatment goal: Do NOT exceed 2 to 3 doses of analgesic medication in one week!

Other treatment strategies

• Daily Preventative Medications:amitriptyline, topiramate (Topamax), propranolol, gabapentin, SSRIs

• Supplementation (coenzyme Q10, riboflavin, chelated magnesium, Omega 3s)

• Physical therapy• Occipital nerve block injections• Biofeedback• Cognitive Behavioral Therapy

Other headache factors/ Setbacks

• Rebound headache (secondary headache)

• Acute illness• Stress, Anxiety, Depression, ADHD and/or behavioral problems

• Repeat injury• Any other chronic disease process

Points to take home

•Education1. Call our office if headaches worsen or new neurological signs develop2. Anticipatory guidance

3. Watch “Head Games” documentary

References and Resources

• Winner, P., Lewis, D. “Young Adult and Pediatric Headache Management”, Hamilton, Ontario; 2005: page 1-232.

• www.achenet.org• www.americanheadachesociety.org• Finkel, A., Guskiewicz, K., Dodick, D., and Conidi, F. Sports

Concussion/Mild Traumatic Brain Injury and Headache. American Headache Society Scottsdale Headache Symposium, November 10, 2011

• Neal, M., Wilson, J. Wesley, H. and Powers, A. Surg Neurol Int 2012; 3:16

• Lau et al. Clin J Sport Med 2009;19: 216-221• Register-Mihalik et al. Clin J Sport Med 2007; 17: 282-288• Gordon et al. Br J Sports Med 2006; 40: 184-186• Wetjen et al. J Am Coll Surg. 2010; 211: 553-7• Halstead et al. Pediatrics. 2013; 132 (5): 948-57