Headaches in Children

1
Headaches in Children

• Dr. Shirsat

2
Headaches in ChildrenObjective

• Learn the Causes of Headaches in Children.
• Learn common causes of chronic headache and
  common causes of severe headache.
• Learn to evaluate a patient with headache.
• Understand parental concerns.

3
Headaches in ChildrenEpidemiology

• Incidence of Chronic or recurrent headache 40
  by age 7 years. 75 by age 15 years.
• Accounts for 10 referrals to Neurologist.

4
HeadachePathogenesis

• Pain sensitive structures in head. 1)
  Intracranial and extracranial arteries, large
  intracranial veins, or venous sinuses (sensitive
  to stretch and traction).
• 2) Cranial and spinal nerves
  (Supratentorial intracranial structures mainly
  innervated by Trigeminal nerve).

5
Pain Sensitive Structures in The Head

• 2) Posterior fossa Intracranial structures mainly
  innervated by upper cervical roots.
• 3) Common innervation can lead to referred pain
  with poor localization.
• 4) Basal Meninges, Dura are sensitive to
  pressure.

6
Pain sensitive Structures of The Head

• 5) Extracranial structures such as the nasal
  cavity, skin, and subcutanious tissue.

7
HeadachePathogenesis

• Arterial supply 1) Common carotid. Middle
  meningeal cerebral.
• 2) Vertebral. 3) Thyrocervical.
• Neural pathway. 1) Trigeminal. 2)
  Glossopharyngeal Vagus, Upper
  cervical.

8
Pain Pathways

• Supratentorial region Trigeminal nerve.
• Location Frontoparietal, Parietal and
  Retrorbital.
• Infratentorial Region-Glossopharyngeal Vagus,
  Upper Cervical.
• Location-Occipital.

9
Pain Pathways.

• Pain from posterior half of segital
  sinus. Locationipsilateral eye and forehead.
• Pain from middle meningeal cerebral
  arteriesLocation behind eyes.
• Pain from carotid bifurcationLocation. Scalp,ear
  ,nose, teeth,toung,face.
• Internal carotid-Location-deep in eye or ear.

10
Etiology of Recurrent Headaches.

• 1) Vascular headache. Migraine Nonmigrai
  nous.
• 2) Tension-Type Headache.
• 3)Headache due to increased intracranial
  pressure. Space-occupying
  Lesions Idiopathic Intracranial Hypertension.

11
Etiology of Recurrent Headache.

• 4) Seizures.
• 5) PsychogenicDepression,School
  problems,malingering,conversion reaction.
• 6) Other causes. Systemic diseases-ear,nose
  ,throat,face,eyes,TMJ,neck

12
History of Patient With Headache.

• History of Pain.
• Past History.
• Family History.
• Social History.
• Educational History.

13
History of Pain.

• DurationSeconds-Neuralgia,Hemorrhage,seizures Min
  utes- Migraine Hours-Muscle contractions
  ,Inflammation Gradual Traction,
  Psychogenic.

14
History of Pain.

• Intensity. MildMuscle contraction. Moderate
  Traction ,Inflammation Severe
  Migrain, Neuralgia,Hemorrhage.
• Quality-Throbbing-Migrain,Aneurysm
  Constant-Muscle contraction,traction,inflammation.

15
History of Pain.

• Quality-Sharp- Neuralgia
  Bizzar-Psychogenic.
• Progression-Seconds-Neuralgia,Hemorrhage,Seizure
  Minutes-Migraine. Hours-Muscle
  contraction,inflammation. Gradual
  Traction,Psychogenic.

16
Important Questions.

• Do you have more then one type of headache ?
• Are the headaches becoming more severe ,more
  frequent ?
• Can you describe a typical episode?
• Are there focal neurologic signs or symptoms?

17
History of Pain.

• Frequency-Paroxysmal-Migrain,Seizures,Neuralgia.
  Constant-Traction,Inflammation,Muscle
  contraction,Psychogenic.
• Time of occurrence-Am. Traction,Inflammation.
  Pm.-Muscle contractions.

18
Important Questions.

• Does the child look sick?
• What makes the headaches worse?
• What healps the headaches?
• What time of the day do the headaches occure?
• Can you identify precipitating factors?

19
Important Questions?

• What medications and dosages have you used?
• Is there a family history of headache?
• Has anything particularly good or bad happened?
• What do you think is causing headache?

20
Past History.

• History of Renal, Cardiac, sinus, ,dental disease
  or previous trauma.

21
Social And Educational History.

• May identify significat stressors.

22
Physical Examination.

• Growth ParametersChronic illness affectes linear
  growth. Hypothalamopituitary dysfunction may
  disturb growth.
• Head circumferenceIncreased ICPgt prior to fusion
  may accelerate head growth.

23
Physical Examination.

• Blood PressureHypertension.
• Head-Enlarged head- Hydrocephalus, Storage
  diseases. BruitAVM. Swelling
  TendernessInflammation,trauma,neuritis. Macewa
  ns sing-absess,scalp tenderness

24
Physical Examination.

• EyesPapilledemahigh ICP. Disc
  cupping-Glaucoma. Hemorrhage in
  fundus-trauma, high ICP. Decreased
  vision-myopia, tumor,optic neuritis. Field
  loss-tumor stroke, glaucoma,migraine.

25
Physical Examination.

• . Eyes.Gaze paralysistumor, stroke,
  migraine. Muscle paralysis-tumor,high ICP.
• Ears-Otitis,absess Decreased
  hearing-otitis,tumor.
• SinusesPercussion tenderness-sinusitis.

26
Physical Examination.

• Mouth-Tooth tenderness-dental absecess
  Throat inflammation-Pharyngitis,quincy.Jaw
  crepitus-TMJ. Dysfunction.
• Neck-Meningismus-meningitis Tilt-tumor,
  arthritis,strabismus Limited
  mobility-arthritis tonsillitis,adenitis.

27
Physical Examination.

• Skin-Trauma, evidence of Neurocutaneous
  disorder.( tumor)
• Heart-Shunt abscess.
• LungsChronic lung disease with poor ventilation
  .hypoxia.
• Neurologic Examination-Focal neurologic signs,
  signs of increased intracranial
  pressure.-mass,AVM,Migraine.

28
Evaluation ,Who needs It?

• Severe acute onsetNeuroimaging ( MRI,CT.)
• Neurologic deficit( fixed or trasient) Neuroimma
  ging,neurovascular studies) MRI,MRA.
• Progressive headache. MRI,CT.

29
Evaluation.

• If neuroimmaging showed no mass effect LP.
• Chronic headache-Psychological ,psychosocial
  studies,sinus CT,x-ray TMJ.

30
Treatments.

• Treat the cause.
• Non-pharmacologicalBiofeedback and relaxation
  trainingusefull in muscle tension headache, may
  be migraine. Avoid precipitating factors ( diet)

31
Treatment.

• Pharmacologic treatment. Analgesic. ASA,
  ASA Caffeine, Acetaminophen.Acetaminophen
  Codeine Should not be used repeatedly
• Analgesic and other agents. Fiorinol,
  Fioricet, Tylenol with Codeine,Vicodin, Percocet.

32
Treatment.

• NSAIDS Ibuprofen,Toredol,Indocin.
• Narcotics. Stadol, Demerol,Combination with
  phenergan.
• Medications used in reversing migraine. Nonergot-
  Midrin

33
Treatment.

• Medications reversing migraine. Ergot.Cafergot,
  Ergostat,Sumatriptan.
• OthersOxygen,Muscle Relaxant,Steroids.
• Medications used for prevention of
  Migraine. Inderal central action 1 to 3
  mg/kg/day may have depression.

34
Treatment.

• Nadolol.
• Antidepressants. 1) Amitriptyline 25mg to
  2000 mg h.s. 2) Pamelor 3) Nardil ( MAO
  inhibitor) 4) Prozac.

35
Treatment.

• Calcium channel Blockers. 1) Verapamil up to
  320 mg/day in adults. 2) Diltiazem
• Antiserotonin. 1) Cyproheptadine 4 to 16 mg
  /day 2) Methesergide-rarely used in
  children.

36
Treatment.

• Anticonvulsants. 1) Dilantin. 2)
  Phenobarbital. 3) Tegretol. 4) Depakote.