Headaches in Children. Emergency Medicine Royal Hospital for Sick Children, Yorkhill

Transcription

1 Headaches in Children Emergency Medicine Ryal Hspital fr Sick Children, Yrkhill Headaches in Children Versin: 2.0 Page 1 f 7 Authrs: Fina Russell Authrised by Fina Russell Issue Date: May 2014 Revisin date: May 2017

2 Headaches in Children Children cmmnly present t the Emergency Department with headache. Yu must try t evaluate if there is a significant underlying pathlgy. Therefre yu must take a careful histry and perfrm a thrugh examinatin. Histry Questins yu shuld ask in additin t yur usual histry: What was yur child ding when the headache started? Interrupted sleep suggests SOL Headache present n wakening suggests raised ICP Hw lng has yur child had a headache/ headaches fr? First r wrst Shrt histry Changed r accelerated curse In teenagers headache that never ges away suggests SOL What des yur child d when they have a headache? If prhibits nrmal activities severe headache If inhibits nrmal activities mderate headache Agitated and pacing the flr suggests cluster headache What makes the headache wrse? Wrse n lying dwn suggests raised ICP Has yur child s behaviur changed? Altered persnality suggests SOL Has yur child had a recent head injury? Has yur child had any ther symptms? Vmiting particularly early mrning Fever Phtphbia need t cnsider meningitis Headaches in Children Versin: 2.0 Page 2 f 7 Authrs: Fina Russell Authrised by Fina Russell Issue Date: May 2014 Revisin date: May 2017

3 Neck pain r stiffness suggests meningeal irritatin Seizures Did yur child feel anything befre the headache came n? Aura are usually visual disturbances What painkillers has yur child had tday? What painkillers d they have every day? Chrnic use f analgesia may cause Medicine Overuse Headache Hw many drinks des yur child nrmally have in a day? Many children have chrnic headaches secndary t dehydratin D they have a lt f caffeine (cke, irn bru) r fds with mnsdium glutamate (flavured crisps, pt ndles)? Is there any family histry f migraine? Examinatin A thrugh examinatin shuld be perfrmed: Vital signs: pulse, temperature and BP shuld be dcumented in all patients Assess the level f cnsciusness and recrd the GCS General Physical examinatin including: Skin lk fr rashes r cutaneus lesins eg café-au-lait spts Ears and thrat URTI with fever is a cmmn cause f headache Teeth check fr dental caries/abscess Sinus tenderness palpate the frntal and maxillary sinuses Head check fr any sign f trauma Neck lk fr neck stiffness - cervical lymphadenpathy Grwth Chart: Height, weight and head circumference shuld be charted. Full Neurlgical Examinatin including: Fundscpy lking fr papilledema r haemrrhage Headaches in Children Versin: 2.0 Page 3 f 7 Authrs: Fina Russell Authrised by Fina Russell Issue Date: May 2014 Revisin date: May 2017

4 New nset squint r III, IV r VI nerve palsies Fcal neurlgical abnrmalities are ften present in SOLs Ataxia lk at the patient s gait Differential Diagnsis Yu shuld nw be able t categrise the patient s headache int ne f fur types: Type Islated Acute Acute Recurrent Chrnic Prgressive Descriptin Recent nset headache with n prir histry f similar episdes (see Appendix 1) e.g. URTI, meningitis, acute intracranial bleed Attacks separated by symptm free intervals e.g. migraine r tensin type headache Frequency and severity gradually increases with time and usually indicates increasing ICP e.g. tumur, hydrcephalus Chrnic Nn-prgressive Mre frequent and persistent than acute recurrent may ccur daily Investigatin Investigatins will largely be determined by the differential diagnsis. In general patients with Islated Acute headache r thse with Chrnic Prgressive headache will require urgent investigatin and management in the Emergency Department. There is n place fr rutine blds. Bld tests shuld be apprpriate t the differential diagnsis eg FBC, CRP if cnsidering sepsis. CT Scan Requests fr CT scan are cnsultant t cnsultant. Therefre if yu think the patient requires an urgent CT yu shuld discuss the need fr, and the timing f a CT with a senir clleague. Headaches in Children Versin: 2.0 Page 4 f 7 Authrs: Fina Russell Authrised by Fina Russell Issue Date: May 2014 Revisin date: May 2017

5 Indicatins fr CT scanning patients with headache include: Altered GCS Features f increased ICP papilledema, night r early mrning vmiting New fcal neurlgical deficits Seizures especially fcal Cerebellar dysfunctin ataxia, nystagmus etc Persnality change Chrnic prgressive headache Significant head trauma LP - again the timing in relatin t pssible CT shuld be discussed with a senir clleague, but must be cnsidered if suspecting meningitis. Management 1) Acute Headache r Chrnic Prgressive Headache: If there is a specific diagnsis such as meningitis, SAH, systemic r lcal infectin then treat apprpriately. All patients need t have adequate analgesia given as early as pssible. Treat nausea and vmiting eg.ndasetrn If the headache has nt significantly reslved, n matter what the prbable diagnsis the patient will require a perid f bservatin. 2) Acute Recurrent r Chrnic Nn-prgressive Headache These patients shuld be referred by dictated letter t the Headache Clinic run in the Fraser f Allander Unit. The patient will be sent ut a Headache Diary t cmplete prir t their attendance. If Medicine Overuse headache r diet r dehydratin is thught t be a cntributing factr, alteratin in family behaviurs prir t their clinic attendance shuld be discussed. It is nt rutine practice t start any ther drug therapies fr Migraine until they have been assessed at the Headache Clinic. Headaches in Children Versin: 2.0 Page 5 f 7 Authrs: Fina Russell Authrised by Fina Russell Issue Date: May 2014 Revisin date: May 2017

6 Fr further backgrund infrmatin: Evaluatin f Headaches in Children, Mukhpadhyay S et al: Sympsium: Neurlgy Paediatrics and Child Health 18:1 Appendix 1 Imprtant causes f Acute Headache Tensin headache Infectin Lcal Eyes Ears Teeth Sinuses Skin Lymph nde Systemic Viraemia Bacteraemia Meningitis Encephalitis Septicaemia Arterial Hypertensin Inflammatry Disease Lcal Intracranial Cervical Musculskeletal Systemic Kawasaki Disease Lupus Other cllagen vascular disrders Hydrcephalus Intracranial Haemrrhage Brain Tumur Vascular Anmaly Idipathic Intracranial Hypertensin Headaches in Children Versin: 2.0 Page 6 f 7 Authrs: Fina Russell Authrised by Fina Russell Issue Date: May 2014 Revisin date: May 2017

7 Migraine Pst Traumatic 1)Internatinal Headache Sciety Criteria fr Diagnsis f Migraine withut Aura A. At least 5 attacks fulfilling B-D B. Headache lasting 72 hurs (untreated r unsuccessfully treated) C. Headache has at least 2 f the fllwing characteristics: Unilateral lcatin Pulsating quality Mderate r severe intensity Aggravatin by walking stairs r similar physical activity D. During headache at least ne f the fllwing Nausea and/r vmiting Phtphbia r phnphbia E. N evidence f rganic disease 2) Internatinal Headache Sciety Criteria fr Diagnsis f Migraine with Aura A. At least tw attacks fulfilling B B. At least three f the fllwing characteristics: One r mre fully reversible aura symptms. At least ne aura symptm develps gradually ver mre than 4 minutes r tw r mre symptms ccur in successin. N aura symptm lasts mre than 60 minutes. Headache fllws aura with a free interval f mre than 60 minutes (it may als begin befre r simultaneusly with the aura. C. N evidence f rganic disease. Headaches in Children Versin: 2.0 Page 7 f 7 Authrs: Fina Russell Authrised by Fina Russell Issue Date: May 2014 Revisin date: May 2017