14 y.o. female patient with a 2 year history of headaches that have been increasing in intensity and frequency for the past 4 months

Location: Quality: Associated “Autonomic Features:Aggravated by:Improved with:Duration: Family History:

Location: HemicranialQuality: PoundingAssociated “Autonomic Features: Phonophobia,

Nausea, Dizziness, and scalp tenderness (no photophobia). No visual or sensory aura.

Aggravated by routine physical activity, improved with rest and with sleep

Duration: 2 to 8 hoursFamily History: Mother and maternal aunt have

“stress headaches” which occur often with menses

Frequency:Severity:Medication:Triggers:

Frequency: 2 to 3 times per week on averageSeverity: Most headaches are described as

severe with associated missed school and social functions

Medication: Tylenol 500 mg: No help. Ibuprofen 400 mg partially reduces severity. 1° Care MD gave script for Vicodin 7.5/500 which puts her to sleep within one hour. No access to meds at school

Triggers: Menses, stress, hot weather. Drinks one to 3 caffeinated beverages per day.

Vitals:HEENT:C/V:Neurological Examination:

Vitals: BP = 125/65, P= 90, BMI = 28HEENT: No sinus percussion tenderness,

TM’s clear, full ROM of jaw and neckC/V: RRR no murmorsNeurological Examination:

Visual AcuityFundoscopic ExamEOM’sTandem GaitScreening Exam

???

Common Juvenile Migraine

CBC: ?CMP: ?ESR, CRP, ANA: ?TFT’s: ?U Tox: ?EEG: ?LP: ?CT of Brain: ?MRI of Brain: ?

A history consistent with migraine and a non-focal neurological exam without signs of raised ICP are all that are necessary for the diagnosis of

migraine1. Obtaining a neuroimaging study on a routine basis is

not indicated in children with recurrent headaches and a normal neurologic examination (Level B; class II and class III evidence).

2. Neuroimaging should be considered in children with an abnormal neurologic examination (e.g., focal findings, signs of increased intracranial pressure, significant alteration of consciousness), the coexistence of seizures, or both (Level B; class II and class III evidence).

3. Neuroimaging should be considered in children in whom there are historical features to suggest the recent onset of severe headache, change in the type of headache, or if there are associated features that suggest neurologic

dysfunction (Level B; class II and class III evidence). Neurology 2002;59:490-498

? ?

Daily preventative Rx

Right DrugRight DoseRight Timing of

Administration

• At least 2 to 3 disabling headaches per week

• Headaches that are poorly responsive to optimal Acute Symptomatic Rx

Daily preventative Rx

NSAIDSTriptansErgotaminesAspirin/Caffeine

compoundsDopamine AntagonistsTylenolNarcotics have no

antimigraine properties and should be avoided whenever possible

• TCA’s• Ca++ Channel

Antagonists• Anticonvulsants• CyproheptadinePropranolol, while

widely perscribed is poorly tolerated and not necessarily any more effective

Daily preventative Rx

Modifying TriggersGood SleepHealthy EatingRegular exerciseMinimize caffeine usageOCP’s for refractory catamenial migraine

17 y.o. female with a 10 year history of headaches that have been daily for the past 18 months or so

Location:Daily time course:Migrainous features with peaks:Progressive:Remote history of common migraine:?Number of school days missed or work

activities missed:?

Location: Holocephalic, nuchalDaily time course: Daily from awakening until

sleepMigrainous features with peaks: 2-3 hour peaks

with phonophobia and dizziness (no photophobia, no vomiting, moderate in intensity)

Progressive: NoRemote history of common migraine: YesNumber of school days missed or work activities

missed: 17 days missed this year

Acute Symptomatic TreatmentWhat is being usedWhat is the dose How oftenadministered

Caffeine UsageExercise, sleep, eating patternsOther pain symptomsAny depression or anxiety symptomsPsychosocial functioning

Acute Symptomatic TreatmentWhat is being used: Migraine Excedrine What is the dose: Two tabsHow often administered: Three times daily

Caffeine Usage: 4 to 6 beverages dailyExercise, sleep, eating patterns: No exercise,

overweight, insommniaOther pain symptoms: Multiple arthralgias. Dx’d

with fibromyalgia and chronic GI painAny depression or anxiety symptoms: Anxiety

symptoms existPsychosocial functioning: Poor grades due to

absences

Vitals:HEENT:C/V:Neurological exam:

Vitals: BP = 135/78, P = 86, BMI = 42.7HEENT: NormalC/V: RRR no murmursNeurological exam: Non focal. No signs of

raised ICP

Diagnosis

???

DiagnosisChronic Daily HeadacheTransformed Migraine HeadacheMedication overuse Headache

Medication managementTaper off Acute Symptomatic TreatmentTaper off caffeine usageStart Daily preventative therapyPRN NSAIDs with limit one dose/day and 3

doses per weekGoal of keeping the patient functional despite

daily painImportance of exercise, diet, and sleep

A 10 y.o. boy with a two month history of daily headaches

Location:Autonomic Symptoms:Time course of Headaches:Progressive:Exacerbating factors:Relieving factors:Neurological Deficits:Visual Symptoms:Constitutional Symptoms:

Location: HolocephalicAutonomic Symptoms: Repetitive Vomiting upon awakening,

then clears. No anorexia.Time course of Headaches: Daily and progressive without

pain-free intervals Progressive: YesExacerbating factors: Supine posture, valsalva, cough,

sneeze, bending overRelieving factors: Recumbent posture, not moving headNeurological Deficits: None reportedVisual Symptoms: Diplopia without visual

obscurationsConstitutional Symptoms: No fever, weight loss, fatigue.

Vitals:HEENT:C/V:Neurological Exam:

Vitals: BP = 120/58, P = 80, BMI = 24HEENT: No sinus percussion tenderness,

neck with full ROM, no proptosis, TM’s clearC/V: RRR without murmurNeurological Exam:

MS: Alert, speech fluent/articulate, nl concentation and STM

CN: VA = 20/20 OS, 20/25 OD, PEERLA, fundoscopic exam with…

How about this one?

Vitals: BP = 120/58, P = 80, BMI = 24HEENT: No sinus percussion tenderness, neck

with full ROM, no proptosis, TM’s clearC/V: RRR without murmurNeurological Exam:

MS: Alert, speech fluent/articulate, nl concentation and STM CN: VA = 20/20 OS, 20/25 OD, PEERLA, fundoscopic exam

with Bilateral mild-moderate papilledema, cannot fully abduct OS otherwise EOMI, face symmetric, palate and tongue midline

Motor: Nl tone, strength, symmetric DTR’s, downgoing toes Sensory: Nl light touch, cold and vibration sense Coordination: No dysmetria or tremor or titubation Gait: Normal narrow-base gait. Tandem gait intact

???

Raised Intracranial Pressure Due to…Pseudotumor CerebriHydrocephalusBrain TumorBrain AbscessVenous Sinus Thrombosis

The Next Step?

NeuroimagingUrgent CT vs MRI with MR Venogram

The Next Step?

Lumbar PunctureOpening PressureCell Count with CytologyProtein and Glucose

Lumbar PunctureOpening Pressure: 380 mmH2OCell Count with Cytology: 2 WBC (70%

monocytes). No malignant cells.Protein and Glucose: Protein = 24 mg/dl,

glucose 80 mg/dl (serum = 120 mg/dl)

Pseudotumor CerebriTreatment ?

Pseudotumor CerebriMedication Treatment

AcetazolamideOther DiureticsGlucocorticosteroidsOptic nerve Sheath Fenestration

Ophthalmology Follow UpVisual Field TestingHeadache Evaluation

Now get out there and treat headaches with confidence.

Stop unnecessary neuroimaging.Develop a Treatment Plan!

You can do it.