Headaches in Children How to Manage Difficult Headaches

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1 Headaches in Children How to Manage Difficult Headaches Peter Procopis

2 Childhood headaches Differential diagnosis Migraine Psychological Raised Pressure

3 Childhood headaches Other causes: Constitutional Upset Intracranial Infection Trauma Venous Thrombosis BIH Hydrocephalus Ocular Causes Sinusitis Intracranial Haemorrhage Cluster Headache Brain Tumour Low Pressure Miscellaneous

4 Migraine: diagnostic criteria (Prensky) Recurrent Headache with Symptom-Free Interval Together with 3 of: 1. Abdominal Pain, Nausea or Vomiting 2. Unilateral Headache 3. Throbbing Pain 4. Complete Relief after Sleep 5. Aura: Visual, Sensory or Motor 6. Family History of Migraine

5 Paediatric migraine without aura diagnostic criteria A. At least five attacks fulfilling B-D B. Headache lasting 1-48 hours C. Headache has at least two of the following: 1. Bilateral location (frontal/temporal) or unilateral location 2. Pulsating quality 3. Moderate to severe intensity 4. Aggravation by routine physical activity D. During headache, at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and/or phonophobia

6 Paediatric migraine without aura diagnostic criteria A. At least two attacks fulfilling B B. At least three of the following: 1. One or more fully reversible aura symptoms indicating focal cortical and/or brainstem dysfunction 2. At least one aura developing gradually over more than 4 minutes, or two or more symptoms occurring in succession 3. No aura symptoms lasting more than 60 minutes 4. Headache follows after less than 60 minutes

7 Shakespeare King Henry IV (2) King - Prince Henry- And now my sight fails and my brain is giddy. O me! Come near me now I am much ill Let there be no noise made, my gentle friends If he be sick with joy, he ll recover without physic.

8 Suspect raised intracranial pressure if: Recent Onset of Headaches Early Morning Headaches Occipital Headache Cough-Strain Headache Signs of Raised ICP Neurological Signs Altered Personality, Behaviour Loss of Skills

9 Indications for Investigation of Headache Suspicion of Raised ICP Failure to Return to Normal Between Attacks Increasing Frequency & Severity of Attacks Headaches not Relieved by Analgesics Decreased Growth

10

11

12 Migraine Treatment of Acute Attack: Quiet cool dark room Paracetamol or NSAID Anti-emetic Sleep Sumatriptan Combination of NSAID & triptan may be superior

13 Sumatriptan 5 HT Agonist Side Effects: Perioral Dysaesthesia Chest Pain Feeling of Unreality Vasoconstriction

14 Sumatriptan Nasal Spray: Nasal Sumatriptan is effective in treatment of migraine attack in children: a randomized trial. Ahonen K, Hamalainen ML et al Neurology :

15 Migraine in Children Keys: Accurate Diagnosis Exacerbating Factors Medication Overuse Continuing Management

16 Headaches in Children Modify Risk Factors: Medication Overuse Hunger & Thirst Obesity Snoring Sleep Disorders Excess Caffeine Psychological Factors Head Injury

17 Migraine Interval Therapy: Indicated if significant interference with normal life and schooling, acute treatment ineffective or overused, headaches intensive & > 48 hr. Beta blocking agents (eg. propranalol) Topiramate (more effective than propranalol but > s/e s Sodium valproate Flunarazine (calcium blocking agent)? Amitriptyline Pizotifen ineffective Other agents have not proven to be effective in children

18 Childhood Migraine Complementary Medication: Butterbur AAN, American H.A Society Canadian HA Society? Stabilises vascular bed Studied in adults & children * Pyrrolizidine free Dose mg bd a.c mg bd a.c >13 75mg bd a.c

19 Childhood Migraine Complementary Medication: Magnesium - Up to 50% children diet deficient Studied adults & children Titrate dose mg per day AAN; Canadian H.S strong rec. Side Effects - diarrhoea Use chelate or glycinate

20 Childhood Migraine Complementary Medications: Feverfew conflicting results CoQ10?? Riboflavin conflicting results

21 Childhood Migraine Acupuncture Cochrane Review At least effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Also for tension headaches

22 Childhood Headaches Prognosis: 50% Free of Attacks by Age 13 80% Well after 8 years

23 Childhood Migraine Prognosis Bille (1997) - 73 children - ave. onset 6 yrs - 40 yr follow up 23% migraine free by age 25 Age 50: >50% still had migraine

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