headache babcock
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Pediatric Neurology Quick Talks
HeadacheMichael Babcock
Summer 2013
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Scenario
• 7 yo boy
• Headaches for 4 months
• Headaches last 90 minutes• rabs the front of his head !hen it hurts
• Has about 1 headache a !eek" #omits !ith some of the headaches
• $ontinues to do !ell in school" no #ision com%laints
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Causes of headache
• &rimary
' Mi(raine
' )ension*ty%e ' $luster
' &aro+ysmal hemicrania
' S,-$)
' )ri(eminal neural(ia .not
common in kids/ ' $hronic daily headache
• Secondary
' Medication o#eruse
.rebound/ ' headneck trauma
' ascular disorder ' SH"
M" #asculitis" $S)
' Hi(h $& o! $&
' )umor ' nfection
• $-S
• 5ther infections
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History
• Headache ' 6uality" se#erity" location" laterality" onset" time course –
episodic and similar or progressive/changing
• ssociated sym%toms ' systemic sym%toms" fe#er" %ersonality chan(es"seiures
• &recedin( sym%toms ' aura" (radualra%id onset
• 8+acerbatin( features ' mi(raines !orse !ith acti#ity !orse !ith layin(
or nocturnal or !ith cou(hstrainin( ' si(ns of ele#ated $& !orse !ith
standin( ' si(ns of lo! $&:
• Medical history ' -;1" Stur(e*!eber" connecti#e tissue disorder" Sickle
cell" immunocom%romised:
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Exam
• itals ' fe#er" $& si(ns
• ood neurolo(ic e+am
' < ltered mental status ' bnormal eye mo#ements
' isual field testin(
' ;undosco%ic e+am
' ;ocal !eakness
' ,M- si(ns
' bnormal (ait
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Papilledema (normal to severe
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!ork"up• ma(in(
' )rauma
' ssociated seiures
' MS ' bnormal neurolo(ic e+am
' Historical features ' thundercla%
headache" %ersistently lateralied"
%ro(ressi#e course" shunt" chan(e in
%atternty%e" occi%ital headache
' Si(ns of ele#ated $&
' $onsiderations=
• no family history of mi(raine
• > 1 month of headache
• ?oun( a(e of onset
' &rior to &
• $S; analysis
' &seudotumor .H/
• ccurate recordin( of %ressure"
in lateral decub %osition must
e+tend 8@s:
' Menin(itis
• Menin(ismus
• ;e#er
• -e! seiures
• MS
• immunocom%romised
' SH
• )hundercla% headache
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#igraine
• ffects 7A of all children
• $auses 1*17 billion in lost %roducti#ity
• ccounts for 10 million %hysician #isitsyear in ,:S:
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#igraine Classification
• &ediatric mi(raine !ith aura
' t least 2 attacks fulfillin( B:
' t least 3 of the follo!in(• 5ne or more fully re#ersible aura
sym%tom indicatin( focal cortical
andor brainstem dysfunction
• at least 1 aura de#elo%in(
(radually o#er C 4 min or C 2
aura sym%toms occurrin( insuccession
• -o auras lastin( C D0 minutes
• Headache no more than D0
minutes after aura
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#igraine treatment $ %ife"style modification
• Slee% ' don@t #ary by more than one hour on school!eekend ni(hts
• 8+ercise ' re(ular e+ercise" but o#er*e+ercise can cause headache
• Mealtimes ' 3 meals daily" don@t ski% meals• Hydration ' carry !ater bottle ' school e+cuse to carry and (o to bathroom
• Stress ' stress reduction techni6ues
• $affeine ' moderation or sto%
• nal(esic o#eruse
' Eon@t use 5)$ %ain relie#ers more than t!o*three times !eekly ' 5%iates can also cause this
' )o relie#e headache ' ha#e to break cycle" sto% medication" headache
!orse for 2*3 !eeks" then better:
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#igraine #edications " Preventative
• $y%rohe%tadine ' - && ' insufficient e#idence ' histamine and
serotonin anta(onist !ith $a*channel blockin( %ro%erties S8 ' !ei(ht*
(ain and sedation: $an be 5F for youn(er" non*o#er!ei(ht children:• Beta*blockers ' conflictin( e#idence: S8 ' asthma" EM" orthostatic
hy%otension" de%ression" not (ood for athletes
• mitry%taline .)$@s/ ' de%ressinoaffecti#e disorder often co*morbid
!ith mi(raines: S8 ' G) %rolon(ation ' (et 8F" beha#ior chan(e
• $a*channel blockers ' era%amil ' (ood for hemi%le(ic mi(raine
• 8E@s
' )o%ama+ ' S8 ' !ei(ht loss" co(niti#e chan(e" sedation
' Ee%akote ' S8 ' !ei(ht (ain" &$5S" terato(enic need $B$;)
monitorin(
' Fe%%ra ' consider because lo! S8 %rofile
' aba%entin ' S8 ' sedation
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#igraine #edications $ &'ortive
• -a%ro+en .le#e/ ' 10*20m(k(d di# GH: ;or %atients o#er 30k(: $an (i#e 1*2
tabs at onset" 1 more tab in hours:
• Motrin
• ;ioricet .acetamino%henbutalbitalcaffeine/ or fiorinal ' (ood for rescue but risk ofde%endance" o#eruse ' %robably best not to (i#e outside 8E:
• nti*emetics ' &hener(an" Ie(lan" $om%aine ' can (i#e benadryl to hel% !ith
slee%e+tra%yramidal effects
• )ri%tans ' Sumatri%tan .&5" S$" -/ ' dult oral &5 dose is 2J*100m( at onset"
ma+ 200m(day &5: -o dosa(e recommendations for children in %acket: S8** heart
' #asos%asm" M" arrhythmias" H)-" stroke" seiure" rebound headaches
chestKa!neck %ain:
• 8r(ots ' nasal EH8 .Mi(rinal nasal s%ray/ ' 1 s6uirt in each nostril ' S8Lchest
%ain" nausea" cannot use !ithin 24 hours of tri%tan
• n 8E ' hydration !ith -S" Ma(nesium" Ee%akote" Fetorolac if not medication
o#eruse" com%aine" benadryl" steroid
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eferences
• htt%=eye!iki:aao:or(&a%illedema
• htt%=!!!:kello((:umich:edutheeyesha#eitac6uired%a%illedema:html
• - &ractice %arameter ' mi(raines
• Maria" B: 2009: $urrent mana(ement in child neurolo(y: &eo%le@s medical
%ublishin( house:
http://eyewiki.aao.org/Papilledemahttp://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.htmlhttp://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.htmlhttp://eyewiki.aao.org/Papilledema