Ann Mazzeo, APN May 2015 HILTON HEAD ISLAND, SC
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1 Ann Mazzeo, APN May 2015 HILTON HEAD ISLAND, SC
2 Identify headaches as a presenting symptom in the child with a brain tumor Discuss the importance of a headache history Recognize risk factors in the headache history for brain tumors Identify indications for ordering an MRI on a child with headaches
3 ! Common reason to seek medical attention! Wide range of causes! Most are primary! Source of worry for parents
4 ! Accepted standard and classification system for headaches! Groups headaches based on symptoms and patterns! Distinguishes primary and secondary headaches
5 ! Most common type of headache in children! Headaches without organic disease or structural abnormalities! Migraine, tension, cluster headaches
6 ! 10% of headaches in children! Evidence of a causal relationship! Reduction or resolution with treatment or in some cases spontaneous resolution! Not necessarily harmful! Brain tumor
7 The poor historian When the story just doesn t make sense The family that can t agree on anything It s Not Always Easy!
8 Date Time headache began Time headache ended Warning signs (aura) Location of pain Type of pain (pressing, throbbing, sharp, etc) Intensity of pain- #1-10 (#1 mild to #10 intense) Other symptoms (nausea, vomiting, visual changes) Medication taken/ Other treatment and effect/relief obtained MENSES: Start and end date of menstrual cycle if applicable How headache affected my normal routine Hours of sleep the night before the headache What I ate before the headache (caffeine, diet soda, chocolate, hot dogs, artificial sweeteners, processed foods. Activities prior to headache Important or stressful events that occurred. Inc. any additional comments. The Headache Diary
9 CHARACTERISTICS OF HEADACHES Please check the answers below that describe your headaches: Would you describe the pain as: Throbbing or pounding Stabbing A dull ache Other Please specify: Does the pain get better with any of the following? While jumping or playing Coughing or sneezing Staying in a dark room Ice Message Sleep or rest Does the pain get worse with any of the following? While jumping or playing Coughing or sneezing Staying in a dark room Ice Message Sleep or rest
10 History Guides the way in considering headache as primary vs. secondary Neuro Exam and Diagnostic Tests Rule out secondary causes
11
12 ! Recurrent headaches are common in children! Diagnosis should be made on a clinical basis! Routine use of diagnostic studies is not indicated when the history has no associated risk factors and the neuro exam is normal
13 ! Abnormal neurological finding on exam! History has an associated risk factor
14 ! The longer the headache history without finding abnormal neurologic findings, the less likely the cause of headaches is due to a brain tumor! Does the start of the headache coincide with an illness, trauma, stress?
15 Sudden Onset Increased Frequency Progressive Persistent Consider MRI
16 Are they persistent? What makes them go away? Children get distracted
17 ! Persistent: Think pathologic! Look at the pattern! School days: Maybe stress? Eye strain?
18 ! Awakens From Sleep! Upon Awakening in the AM
19 ! Persistent headaches! Sleep related headaches
20 Location of pain doesn t always give a clue
21 ! The Worst Headache Ever does not predict a brain tumor! Not easy to assess in children! Pain Scales may help! Have a child draw a picture
22 ! Weight loss or gain! Short Stature! Stamina! Menstrual Cycle! Consider MRI in child with headaches and endocrine abnormalities on history
23 ! Change in gait?! Clumsiness or falling?! Head tilt?! Abnormal eye movements?! Weakness or a limp?! Staring, bed wetting, seizures?! Consider MRI for positive history
24 ! Family history of migraine?! Do you have any birthmarks?! Do other family members?! Ask about development! Ask about school performance! Consider MRI for positive history
25 When the History Includes Risk Factors:! Sudden onset of headaches! Persistent headaches! Sleep related headaches! Endocrine abnormalities! Neuro abnormalities on history or exam! Seizure history
26 ! Change in school performance! Developmental delay or regression! No family history of migraine! Café au lait or hypo pigmented lesions
27 Medicine is not always black and white Use your best judgment
28 94% had abnormal neurological or ocular findings at diagnosis (Honig and Charney) 85% had headaches within 2 months of diagnosis 66% had sleep-related headaches Monitor children closely during the first 4 months of a new headache history
29 Children! 4000 new diagnoses per year in the US! 30% of all cancers! Increased incidence 0 to 4 years! PNET! Infratentorial 65%! Supratentorial 35% Adults 62,000 new diagnoses per year Less than 2% of all cancers Over 40 Gliomas Supratentorial
30 Pediatric Cancer Incidence! Children: ~15,000 new cases per year! Adults: ~1,500,000 new cases per year Children Adults
31 ! Brain tumor symptoms are based on the location of the tumor Vary across the life span
32 ! Children with brain tumors have headaches! Very rare for a child to present with a headache alone! Children with brain tumors have abnormal neurologic exams or risk factors identified on history
33 ! 5-year-old male with a Glioblastoma Multiforme
34 ! The following symptoms occurred 2 months before diagnosis: Change in handwriting Headaches Left-sided-weakness Slurred Speech MRI ordered: Right Thalamic Mass! Headaches increased in frequency. Onset within 2 months of diagnosis
35 ! Partial tumor resection, Cranial Radiation, Chemotherapy! Back to School
36 14 year old boys with diagnosis of Medulloblastoma
37 Acute onset of headaches Headaches increasing in frequency Headaches in AM Clumsy gait MRI ordered: Posterior Fossa Mass Headaches were sudden, persistent, sleep-related
38 ! Complete resections of tumors, craniospinal radiation, chemotherapy! In College and doing well!
39 ! 10 year-old girl with an Astrocytoma
40 Decline in school performance and struggled with math Persistent headaches Generalized seizures MRI was ordered: Right Parietal Mass Headaches were persistent and developed within 2 months of diagnosis
41 ! Complete Resection of her tumor, Cranial Radiation, Chemotherapy! In high school and doing well!
42 ! They all presented with headaches that developed within a few months of diagnosis! They all had risk factors identified on history! Their stories unfolded and an MRI was ordered! They all have been treated for their brain tumors
43
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