Childhood Headache

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Slide 1 :

Childhood Headache Rachel Howells

Slide 2 :

Learning Outcomes By the end of this session, you should be able to Differentiate primary from secondary headache Recognise and manage common primary headaches

Slide 3 :

Epidemiology Preschool 1/3 will have had a headache Migraine headache 0-7% of population Schoolchildren 70% have = 1 headache a year Peak at 90% at age 12-13 Prevalence of recurrent headache 20-30%

Slide 4 :

Case 1

Slide 5 :

Case 1 15 year old girl Frontal headache, down neck and shoulders 2 months Start as soon as she rises from bed, and relieved by lying down Missing school for 6 weeks

Slide 6 :

Primary or Secondary?

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Case 1 Further history Spinal surgery 3 months ago Epidural anaesthesia Examination Normal

Slide 8 :

Low pressure headache Possible dural tap Management Encourage mobilising Many spontaneously resolve within 3-4 months Short-term: Caffeine Long-term: Epidural blood patch

Slide 9 :

Primary vs Secondary Headache

Slide 10 :

Primary vs Secondary Headache 10% of headaches seen in a specialist neurology / headache clinic are secondary in origin Population prevalence of organic disease is likely to be lower

Slide 11 :

Secondary Headache Types Altered Intracranial Pressure Raised ICP Low Pressure Headaches Vascular Subarachnoid Headache (eg AVM) Dissection Vasculitis Drugs Drug effect Analgesia induced headache Central (thalamic) pain Trigeminal neuralgia Cluster headaches Local Dental Abscess Sinusitis Post head injury

Slide 12 :

How to identify a secondary headache

Slide 13 :

How to identify a secondary headache Brain Imaging Examination History

Slide 14 :

Indications that a headache is secondary to altered intracranial pressure

Slide 15 :

Indications Timing of headache Postural manoeuvres Associated symptoms

Slide :

Slide 19 :

Case 2

Slide 20 :

Case 2 16 year old girl seen in OPD Frontal headache There when she wakes, gets better when she gets up No nausea or other neurological symptoms 4 months, not getting any worse

Slide 21 :

Primary or Secondary? Is this raised or low intracranial pressure?

Slide 22 :

Case 2 continued Past History – nil Examination Enlarged blind spots on confrontation No other alteration of visual fields Papilloedema No ataxia, long tract signs

Slide 23 :

What diagnoses need to be considered?

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Causes of Raised Intracranial Pressure Hydrocephalus Tumour obstructing CSF pathways Obstruction to CSF re-absorption (post haemorrhage or meningitis) Congenital (eg aqueduct stenosis) Cerebral oedema Inflammation (ADEM, stroke) Infection (meningitis etc) CO2 retention (obstructive sleep apnoea) Metabolic (DKA, other) Idiopathic (Benign) Intracranial Hypertension

Slide 25 :

Idiopathic Intracranial Hypertension Aetiology unknown Adolescent girls Obesity, drugs, steroid withdrawal Visual loss (10%) may be permanent and is only indication for treatment Raised intracranial pressure in the absence of space occupying lesion or obstruction to CSF flow

Slide 26 :

Indications Timing of headache Postural manoeuvres Associated symptoms

Slide 27 :

Case 3

Slide 28 :

Case 3 14 year old girl Headache since the evening before Single and worst headache ever Sudden onset Vomited once at start No history of head injury / prodrome

Slide 29 :

Case 3 Examination Afebrile No meningism GCS 15 Unilateral facial weakness with frontal sparing Ipsilateral arm weakness with hyporeflexia

Slide 30 :

What diagnoses should you entertain?

Slide 31 :

CT brain

Slide 32 :

Case 3 CT shows haemorrhage around area of left basal ganglia Patient admits to using some cocaine at a party with her 18 year-old sister

Slide 33 :

More information to help you identify secondary headache History

Slide 34 :

Timecourse Single or first severe headache Recurrent severe headaches One a month 2 years without progression Headaches all day on most days 18 months Headaches every few months then weeks then days Now every day Severe headaches all day for 12 days 2 months ago None since Bleed? Bleed? Tumour? TTH? Migraine?

Slide 35 :

Slide 36 :

Pointers in History: Summary Timing of Headache Postural manoeuvres Symptoms associated with headache Timecourse

Slide 37 :

Examination

Slide 38 :

Purpose of Examination To support your clinical impression made on history To rule out other differentials To adhere to many families expectations to be taken seriously to be able to support your view that nothing serious is going on

Slide 39 :

Essential elements of Examination Vision Acuity Fields including blind spot Extraocular movements Long tract signs Tone Power Reflexes Cerebellar signs Finger-nose test (eyes shut) Tremor Dysarthria Gait Blood pressure Bruit Conscious level Fundi

Slide 40 :

Case 4

Slide 41 :

Case 4 8 year old boy with 10 month history of Bi-temporal headache Throbbing Worse with movement / exercise Mother says looks pale and unwell Usually start in morning Last all day

Slide 42 :

Case 4 No family history Examination is normal

Slide 43 :

Primary or Secondary? What is the most likely diagnosis?

Slide 44 :

Migraine without aura

Slide 45 :

What causes migraine? Migraine headache Nerve efferents – trigeminal, vagal Meninges have pain fibres with inputs from trigeminal complex Vasodilation of meningeal vessels Michael Creighton Why do some people get migraine headaches? Genetic Abnormal inhibitory inputs to trigeminal nerve complex

Slide 46 :

Clinical Implications Abnormal inhibition to nociceptive parts of brain Abnormal response to changes in environment eg sleep, diet, smells Pain is exacerbated by noise and light Headache relieved by sleep in a dark room Migraine symptoms Pain involves the face (trigeminal) Throbbing pain (meningeal) Pallor and nausea (vagal) Delia Malchert

Slide 47 :

Migraine Classification Migraine without aura (commonest) Migraine with aura Basilar migraine Ophthalmoplegic migraine Alternating hemiplegia

Slide 48 :

Migraine The diagnosis is a clinical one Families can be reassured by Family history Longevity of symptoms Normal examination Addressing their underlying concerns

Slide 49 :

Management Explanation This is not a tumour Worst in second decade of life Most patients will get fewer headaches as they get older

Slide 50 :

Management 2. Treatment of attacks Analgesia as soon as an attack starts Ibuprofen works best (one RCT) May be supplemented by anti-emetic Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)

Slide 51 :

Management 3. Prevention – control of environment ‘Sleep hygiene’ – regular sleep ‘Diet hygiene’ – avoid long breaks ± snack before bed, avoid caffeine, low amine diet ‘Exercise hygiene’ – regular exercise, maintain hydration Avoid stress – relaxation training, CBT

Slide 52 :

Management 4. Prevention – pharmacological No magic bullet, trial basis only Pizotifen Propanolol Feverfew

Slide 53 :

Case 5

Slide 54 :

Case 5 10 year-old girl with 18 month history of Bilateral headache, mainly vertex Constant Comes on during day Not worsened by walking No aura or pallor / nausea 5/7 days a week, most weeks of the year

Slide 55 :

Case 5 No family history Examination normal Local grammar school Predicted for A grades in 10 GSCEs No external sources of anxiety – stable home, not being bullied Trying to keep going to school

Slide 56 :

Case 5 Alternating ibuprofen 400mg and co-codamol for headaches ‘Nothing really works’

Slide 57 :

Primary or secondary? What is the most likely diagnosis?

Slide 58 :

Chronic Tension-Type Headache

Slide 59 :

How is the diagnosis made?

Slide 60 :

CTTH No features suggestive of organic disease Time of day Postural manoeuvres Associated symptoms Time course Not classifiable as migraine Examination normal

Slide 61 :

Management Explanation Although not an organic disease, effects on life can be significant (school etc) Treat attacks Simple analgesia Avoid multiple drugs Feverfew / Levomenthol / TigerBalm

Slide 62 :

Management Prevention of attacks Sleep, diet, exercise hygiene Address anxiety (relaxation training, CBT) Maintain contact with school, try and attend but manage workload

Slide 63 :

What did you learn? You should now be able to Differentiate primary from secondary headache Recognise and manage common primary headaches Migraine with / without aura Tension-type headache

Slide 64 :

Any questions?

Slide 65 :

Thank you for listening Rachel Howells

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