Headaches Practical approach

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HeadachesPractical approach

• Dr Maltby

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Chronic Headache

• Migraine
• Tension headaches/chronic daily headaches
• Teeth/Nocturnal grinding
• Sinus congestion
• Visual
• Sleep apnoea
• Benign Occipital Epilepsy
• BIH
• Raised intracranial pressure

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When to scan

• Very young children
• Change in the character of headaches
• History suggestive of raised ICP
• Focal neurological Signs
• Papillodema not optic detrusum
• Headache with erratic vomiting
• FH or anxiety of IC lesion
• BIH with optic nerve views

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Mausley Study

• Very old study 1998
• Looked at children with CNS tumours mode of
  referral and the symptoms
• Majority DID NOT have symptoms classically of
  raised ICP
• Majority DID NOT have focal neurology
• Majority had frequently been seen by GP
  paediatricians and even a paediatric neurologist

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Conclusions

• Falsely reassured by normal examination
• Signs of ICP are great but dont help
• Change in character in under 5
• School failure in over 5

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Migraine

• Episodes headaches relief with sleep
• Vomiting
• Visual disturbance- specific
• Pallor
• FH
• Motion sickness
• Neurological symptoms vary
• Between times pain free

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Management

• Examination normal
• Scan if under 5
• Advice about treating the acute attack
• Isolating triggers avoidance if possible
• Multiple

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Triggers

• Dietary dairy, citrus, tomatoes, blackcurrant,
  fizzy drinks J2O
• Sleep excessive weekend lyins or sleep overs
• Excitement
• Stressed out
• Busy life

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Busy lives

• After school clubs
• Sibs after school clubs
• Weekend activity
• Sleep overs
• Home work plans/supervision
• Friendships
• Sport activities
• Rushing mothers

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Management of acute attack

• Immediate analgesia- emergency protocol
• Write to the school for their support
• Ibrufen, Migraleve
• If vomiting Migraleve
• Very rare to need Sumitryptin
• Monitor school attendance maybe late attendance
  better than none

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Preventive management

• Depend on the frequency school attendance
• Diet exclusion
• Recognise triggers
• Pziotifen
• Others treatments- Topiramate, Epilum,Gabapentin,
  Amitriptyline

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Chronic daily headache

• Teenagers
• High achievers
• Driven from within not by school/parents
• Lots of mates- squabble or miss no mates
• Area of stress in family home
• Not helped by analgesia
• Never wake with headache but have it at night
• Most difficult to manage

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ManagementGeneral advice

• Fluid intake
• Regular meals- diet restrictions
• Regular exercise
• Regular sleep patterns lying in!
• TV and computer usage
• Analgesia usage
• Normalising life
• After school clubs and in sibs
• Avoid asking do you have a headache
• Family attitude to illness

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• Explanation
• Stressy teenagers learn to relax- pilartes
• Advice about studying
• Driven from within
• Learn to live with it

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Treatment strategies

• Dietary exclusion formally not by diary
• Diary shocking what they eat
• Exclude for 6 weeks
• Diary products
• Citrus/Apples in any form
• Tomatoes and ketchup
• Fizzy drinks
• Blackcurrant drinks
• Chocolate
• Marmite
• Anything else you can think of especially if the
  love them
• Replace one thing every 4 days if there was a
  response

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Medication

• Diet fails or the child cheats or refuses
• Explanation of pain modification the pain is
  there but the response is different
• Trail of Pziotfen ONLY at night for at least 6
  weeks
• Topiramate
• Gabapentin
• Epilum

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Alternative treatements

• Butterbur
• Migraine support group
• Headache clinics
• CAMS

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BIH

• DO not diagnosis this unless confirmed
  papillodeama and optic nerve swelling on MRI
• Reproducible reduction in visual acuity
• Formal visual fields assessment is poor even in
  teenager
• Child has a risk factor obesity and
  tetracycline usage

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Diagnosis

• Raised pressure on opening at LP
• Not under GA straightened legs
• Pressure above 20
• Therapeutic and diagnostic procedure so reduce
  pressure to 20 if over 40 then halve it
• Dramatic response to LP in terms of treatment

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Pitfalls

• Repeated LP
• Refusal to allow it without a GA
• Symptoms from LP confuse the picture
• Side effects from the Diamox
• Evidence that evolves residual chronic daily
  headache
• Bolt monitoring

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• Questions?

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• Hard work

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Fits Faints and Funny turns
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Noah

• 18 months
• Three episodes when his mother says he is found
  on the floor unresponsive floor and jerks lasts
  about 30mins but father thinks less.
• Preceded by a cry
• After he appears confused and inconsolable
• EEG performed by the SHO after being seen in A/E-
  normal
• ECG normal QTc 0.42sec
• 24hr ECG normal
• FH father used to do this as a child and was
  treated with Phenytoin
• Comes to discuss if they should give a trail of
  anticonvulsant

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Ellie

• 12 years of age
• C/O fit at school
• Fat lasting 5 minutes witness by the first aider
  (whose sister used to have fits)
• Called 999 by the maths teacher was sick and
  confused afterwards
• In A/E now feeling better fully conscious a
  slight headache
• B?S by paramedics 6.5
• PMH febrile convulsion resulting in an PICU
  admission for 24 hours given rectal diazepam
   that mother still carries
• FH Mother has epilepsy on Tegretol
• Exam normal
• No focal signs to find
• One café au lait  spot
• Referred to you asking if they could attend first
  fit clinic and an EEG has been organised

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Part two - clinic

• Further episode occurred during home tec and at
  home witness by her older sister
• School refuse to have her back unless some
  things is done
• Mother is sleeping in her bedroom on the floor
• EEG non specfic changes has occasional spikes

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MAX

• 4 years of age- 8 daily episodes cries sits down
  goes rigid eyes roll back lasting 2mins then
  confused afterwards for a bout 30mins.
• Described as pale
• Max says he feels dizzy before hand.
• Neurodevelopmental normal
• No other reported problems absence episodes
  reported by the nursery but not noted at home
• PMH sinus bradycardia as neonate seen by
  Cardiologist at GOS happy with him
• Examination normal HR 70 nil else
• Echo normal
• ECG normal
• Normal QTc -0.44sec
• 24hour tape mum went to anyway not cancelled

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Differential diagnosis of a seizure

• Syncope-         Vasovagal
•                         Cardiac causes-
  cardiomyopathy/prolonged QTc
• Breath holding
• Reflex anoxic seizures/ Reflex anoxic syncope
• Psuedo sezuires
• Emotional syncope
• Valsalva/ constipation
• Stereotypical behaviours
• Tics
• Gratification habits
• Basilar migraine
• Paroxysmal spasmodic torticollis
• Benign paroxysmal vertigo

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• TAKE A HISTORY THE EVENT AND THE RUN UP AND
  AFTER.
• If your not sure adopt watchful waiting DO NOT
  order an EEG unless you think it will give you
  information and interoperated the information
  with the clinical case
• Give advice

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1. What are the risk for a reoccurrence after one
   seizure? After two seizures?
2. What should you tell them to do at school?
3. Whats the advice regarding swimming?
4. Whats the advice about sleeping arrangements?
5. Whats to do about TV and computer games?
6. Any other advice?
7. You reg wants to give them Midazolam prescribe it?

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• Is the episode a seizures?
• Whats the cause of the seizure?
• Is this epilepsy?
• What is the cause of the epilepsy? ---------- NOW
  think EEG
• Classify epilepsy into a syndrome?

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• www.stars.org.uk

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• www.epilepsy.org.uk/info

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• Epilepsy advice and information
• What is epilepsy?
• Caring for a baby or young child when you have
  epilepsy a detailed guide
• Children
• Depression and epilepsy
• Developing epilepsy in later life
• Disability Discrimination Act (UK)
• Driving and epilepsy
• Education
• Entitlements and benefits for people with
  epilepsy
• Epilepsy and learning disabilities
• Epilepsy and Travel abroad
• Epilepsy information for prisons
• Epilepsy, osteoporosis and osteomalacia
• Flu and epilepsy
• Getting a diagnosis
• Identity jewellery
• Inheritance
• Living with dificult to control epilepsy