Headache in children

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Headache in children
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Headache

• Frequent symptom in children
• Parents are worried
• Occasionally it may indicate a severe underlying
  disorder like brain tumor hence careful
  evaluation of children with unconventional
  headache is necessary

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• Most important causes of headache in children
• Migraine
• Increased ICP
• Psychogenic / stress headache
• Refractory errors /Strabismus / Sinusitis and
  Malocclusion of teeth - less common

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• Meningitis
• Brain abscess
• Tumor
• Head trauma
• Post LP
• AV Malformation
• Post Traumatic
• Viral fever, Malaria, Typhoid, Sinusitis, dental
  infection, Mastoiditis, HTN, Refractory errors

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Red flags

• Recent / severe acute onset
• Early morning / Progressive Headache
• Associated with fever /other systemic features
• Neurological signs / Neck Rigidity
• Signs of raised ICP
• Seizures

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A Clinical Approach to Headache in Children

• One can begin by placing a particular child with
  headache into one of following four clinical
  Headache syndrome patterns
• Nearly all patients with headache more or less
  follow these patterns

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Pattern I

• Here the child comes with first attack of
  headache and this is typically represented by a
  child who has no previous history of headache
  except the current one that appeared abruptly and
  made his parents go to see their physician.
• This variety of headache poses the greatest
  diagnostic dilemma

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Pattern I

• It could be the first attack of migraine
• But it could be any thing else as well

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Case 1

• A 6 year old child is brought to you for an
  intense headache since two days.
• What history will you elicit ?

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ASK

• First episode?
• Trauma?
• Associated neurological symptoms i.e. mood,
  drowsiness, vomiting, seizures etc ?
• Other associated features e.g. fever, myalgia?
• Disruption of sleep, relieving factors, and sick
  or well during periods of relative relief?

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Case 1 contd

• The mother says he has run a low grade fever
  which responded well to paracetamol and allowed
  him to sleep for four hours. This is the first
  time ever he has had this symptom and she is
  worried because she has migraine.
• What signs will you look for ?
• Would you diagnose migraine ?

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Look

• Sick or well ?
• Vital signs
• Neurologic examination, notably neck stiffness
• Sinus tenderness
• Fundus
• Systemic exam for pallor and splenomegaly

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Headache

• Recent Onset / First Episode

Long-standing (weeks to months)
No Associated Features
Recurrent
Near continuous
Elicit criteria for migraine
Observe
Associated features fever, myalgia, URI
Consider sinusitis Evaluate social history Record
blood pressure Evaluate refractory error Be
alert for red flag signs
MIGRAINE
Investigate source of extra-cranial infection
Be alert for intra-cranial infective focus
Imaging SOS
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Pattern II

• A child who gives a history of attacks of
  terrible headaches
• He already has a chronic intermittent or
  relapsing pattern of headache

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Pattern II

• In 9 out of 10 cases, there is nausea or vomiting
• Some days, the child is real bad but next day he
  may be perfectly fine and participates in all
  activities
• Attacks of headaches are repeated weeks to months
  later and in between the attacks he is headache
  free

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Pattern II

• This is therefore a syndrome of Recurrent Acute
  Headaches with accompanying nausea or vomiting
• The diagnosis here is usually Migraine

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Pattern III

• The next group of headaches is the one associated
  with organic diseases of the brain and head
• This is the group that the physicians need to be
  cautious and alert about
• The physicians job here is first to convince
  himself and then convince the parents and the
  child that there is no major organic disease

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Pattern III

• Any headache in a child that gets worse over a
  period of time should however alert the physician
• Here, definition of worsening includes two
  features
• Headaches become more frequent than ever and
• They become more severe than ever

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Pattern III

• Such headache attacks might occur first thing in
  the morning
• After the onset they may plateau for a while and
  then they may become worse again
• They might last all day with increasing or
  variable severity
• They might even disappear for a couple of days or
  even a week and return with greater severity and
  can follow a pseudo intermittent pattern

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Pattern IV

• In this group the child has headache everyday and
  often first thing in the morning.
• It is present nearly all day and for several
  days in a week and is aggravated by exercise and
  is relieved only partly by rest

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Pattern IV

• The only other accompaniment is some dizziness
• These patients do not have signs of raised
  intracranial pressure and the neurological
  examination is perfectly normal

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Pattern IV

• This is probably a Stress related syndrome

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• However, one must remember that some children may
  have a mixed pattern which is a blend of more
  than one variety and which can confuse the issue

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Case 2

• A 4 year old child presents with a near
  continuous headache since 3 weeks .
• How would you approach his problem ?

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ASK

• Neurological symptoms and signs
• Temporal profile
• Associated features vomiting ?
• Sick or well ?
• Sleep disturbed?

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Case 2 contd

• Parents say he is drowsy and has gone off food
  for the last week. He often vomits in the middle
  of the night and then falls off to sleep .
• What will you look for on examination?

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LOOK

• Vital signs (including BP)
• Signs of raised intracranial pressure
• Neurological examination
• Fundus examination

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Headache

• Recent Onset / First Episode

Long-standing (weeks to months)
No Associated Features
Recurrent
Near continuous
Elicit criteria for migraine
Observe
Associated features fever, myalgia, URI
Consider sinusitis Evaluate social history Record
blood pressure Evaluate refractory error Be
alert for red flag signs
MIGRAINE
Investigate source of extra-cranial infection
Be alert for intra-cranial infective focus
Imaging SOS
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INVESTIGATIONS

• CT is the preferred initial cerebral imaging
  study because of its sensitivity in detecting
  acute blood
• MRI is a secondary cerebral imaging procedure for
  acute headache because of its inability to detect
  acute blood
• Better than CT in detection of Sub acute bleed
  and is especially useful in suspected sub acute
  subdural hematoma

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INVESTIGATIONS

• MRI is also superior to CT and even to
  angiography in the detection of vascular
  malformations
• MRI is superior to CT in detection of parenchymal
  lesions and visualization of the posterior fossa
  and inferior temporal lobes

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INVESTIGATIONS

• MRA Cerebral venous thrombosis
• Lumbar puncture - Meningitis, SAH, Pseudo tumour
  cerebri
• EEG Suspected seizures

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TREATMENT

• Although consensus does not exist regarding the
  criteria to start prophylactic treatment,
  frequency and severity will be the main factors
  to guide the decision.
• Also, the efficacy of the symptomatic treatment
  and the opinion of child and parents should be
  considered.

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• The drug should be chosen carefully according to
• headache type
• (eg. beta-blockers or cyproheptadine for migraine
• Amitriptyline for migraine or tension-type
  headache)
• frequency
• (eg. Amitriptyline for more frequent/chronic
  headache)

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• type of symptoms
• (cyproheptadine if prominent vomiting),
• side effect profile
• (eg, no beta-blockers if asthma)
• and individual tolerance and efficacy guides
  adjustments
• Finally, it is advisable to include co morbidity
  in the choice, such as depression and insomnia,
  which a tricyclic antidepressant helps to control
  along with migraine.

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• Beta-blockers - Propranolol
• Antihistamines - Cyproheptadine
• Anticonvulsants - Divalproex sodium,Topiramate
• Calcium channel blockers - Verapamil
• Antiemetics Promethazine
• Triptans Sumatriptan, Dihydroergotamine
• Tricyclic antidepressants Amitriptyline
• Carbonic anhydrase inhibitors Acetazolamide
• Analgesics - Acetaminophen

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Treatment/Tension-Type Headaches

• Beta-Blockers PropranololAntidepressants/Tricycl
  ics (Non-Sedating) ProtriptylineDesipramine

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Treatment/Tension-Type Headaches

• Abortive Treatment/Tension-Type Headaches
• Biofeedback
• NSAIDs IbuprofenDiclofenacKetorolacFlubiprofen
  Meclofenamate
• Others Methysergide maleate

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Non pharmacologic measures

• Relaxation techniques with biofeedback of either
  cutaneous temperature with a finger probe or
  muscular contraction with an electromyography
  (EMG) needle