Evaluation Headaches in Kids

Transcription

1 Evaluation Headaches in Kids Richard D. Magie, D.O. KCUMB Peds Department Blessed is the person who finds wisdom*, the person who gains understanding, for she* is more profitable than silver and yields better returns than gold.---solomon 1 1

2 Learning Objectives 1. Participants will be able: Evaluate the child who has headaches. Recognize the signs/criteria for diagnosis of migraines in children. Recognize the need for neuroimaging in children with complaint of headaches Discuss treatment regimens for different types of headaches in children Migraine Tension Chronic headache disorders 2 2

3 Do kids really have headaches? Headache is a relatively common complaint in the office as well as the ED 90% of school age kids have complained of a headache (58% each year). Prior to puberty headaches are more common in males Up to 10% of kids ages 5-15 years have migraine headaches 1 in 8 males and 1 in 5 females have been in ED or office with HA as the chief complaint. 3 3

4 Types of Headaches Acute Acute recurrent Chronic progressive Chronic nonprogressive 4 4

5 Acute Headaches Sudden Onset Migraine* URI (viral or streptococcal pharyngitis)* Meningitis/encephalitis ICH Mass Toxic exposure Trauma Stroke Malignant hypertension Vasculitis 5 5

6 Migraines Common diagnosis in children 3-7% ages 3-7 years. Up to 23% in adolescence. Without aura are more common than with aura. Hard to diagnose in the younger kids as cosymptoms may be more impressive than the HA. Family history is helpful, should include multiple generations. 6 6

7 Migraines* Common Triggers (kids): Stress let up after stress Fatigue (poor sleep pattern) Illness Fasting Dehydration (acute or chronic) Foods (less common than expected) 7 7

8 Migraines: Neurologic Disorder Complex Mechanisms (same as adults) Interactions between neural and vascular systems Includes Cortical Spreading Depression Abnormal neuronal excitability Serotonin activity Inflammation Trigeminal neurovascular activation Signal transmission through the thalamus (to cortex) Exact mechanisms remain unclear. 8 8

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13 Genetic Markers of Migraines: Mutations in these sites Calcium channel gene (CACNA1A) Sodium/potassium pump gene (ATP1As) Sodium channel gene (SCN1A) Mitochondrial dysfunction Other mutations are likely Multifactorial-genetics plus Not simple hereditary pattern- Inconsistent expression Skips generations (ask about Grandma, etc) 13 13

14 Presentation of Migraines (Kids) Typically shorter in kids (30-60 minutes) Seek dark rooms Anorexia Nausea/vomiting Sleep extinguishes episode Other Dizziness Blurred vision (difficulty focusing/reading) Pallor Flushing Dark circles around eyes Abdominal pain Sweating 14 14

15 Migraine with Aura Less common (? Due to history ability?) Aura lasts less than 30 (most often 5-20) minutes and occur about 30 minutes before headache, always reversible. May or may not be present with each headache Visual Alice in Wonderland Sensory (numbness, tingling, smells) Confusion Muscle weakness Aphasia Amnesia 15 15

16 Less common Migraine Variants Basilar Aura: vertigo, ataxia, nystagmus, dysarthria, tinnitus/ hyperacusis, bilateral paresthesias, diplopia or other visual changes. Confusional: Aura: altered mental status with aphasia or impaired speech. Triggered by relatively mild head trauma Should rule out chemical impairment Hemiplegic Rare, familial-genetic testing Symptoms are often prolonged 16 16

17 Transition 17

18 Tension Headache Probably the most common of headaches Generally less disabling than migraines Last for ~ an hour to several days Tightening, pressure, or band-like Mild to moderate pain 18 18

19 Tension Headache Triggers Stress Fatigue Illness Muscle fatigue/over use (especially neck and shoulder) 19 19

20 Tension Headache Can be episodic (less than 15 days per month) Chronic (15 days or more per month) Many feel that some of same components of pathophysiology as migraines Occasionally hard to tell from migraines Some of same meds help both types 20 20

21 Transition Slide 21

22 CHRONIC Headaches Three major categories Chronic migraine Chronic tension-type New daily persistent headache (NDPH) 22 22

23 Chronic Migraine History of migraines becoming increasingly frequent until present more than 15 days per month Not unusual to have daily headaches Other symptoms, including aura, may diminish with increasing frequency of HA Nausea, vomiting, etc Severity of HA often decreases also 23 23

24 Chronic Tension-type HA Maybe hard to distinguish from chronic migraines History of previous migraine maybe biggest clue

25 NDPH (New Daily Persistent Headaches) Occurrence of a new headache that becomes daily within 3 days of onset and not related to/caused by another disorder. Should be evaluated for secondary causes. Can be triggered by viral illness, head trauma, surgery or unknown factors

26 Transition 26

27 Secondary Headaches Increased intracranial pressure Uncommon, but important Space occupying lesion Blockage of CSF flow Impaired CSF absorption Increased tissue or fluid volume Edema Hemorrhage Inflammation mass 27 27

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29 Infection Acute viral Other systemic infectious process Meningitis/encephalitis Sinusitis Otitis media 29 29

30 Systemic Infections with HA Symptoms Many acute viral Streptococcal pharyngitis Lyme Disease Bartonella Rickettsial HIV Most have other symptoms with the infection 30 30

31 Sinusitis Can cause or trigger headaches in kids Most actually have primary headache type Sinus related pain Pressure-like, dull periorbital Worse in the AM Has associated nasal congestion Lasts for days Generally-no nausea, photophobia, visual changes, or phonophobia

32 Meningitis and Encephalitis 2-9% of kids with HA in the ED Has-photophobia, nausea, vomiting, and pain with eye movements. Typically Fever Altered mental status Nuchal rigidity 32 32

33 transition 33

34 Structural Disorders-1 Chiari I malformation Herniation of cerebellar tonsils below foramen magnum Classically Occipital HA Ataxia Weakness Vertigo CN or sensory nerve dysfunction Up to 30% with x-ray findings are asymptomatic 34 34

35 Chiari Malformation 35

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37 Structural Disorders-2 Neuroimaging Indicated Tumors - uncommon cause of HA in kids Space occupying lesions Arachnoid cyst Vascular malformation Evidence of tuberous sclerosis or neurofibromatosis Radiation exposure (history) 37 37

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39 PE-somewhat changed Not as well oriented Right pupil 5mm left pupil 2 mm 39

40 Left Right 40

41 TRANSITION IMPORTANT SECTION 41

42 Indications for Neuroimaging-1 Progressive pattern Increased severity/frequency Medication becoming ineffective Worsening with Valsalva, straining, cough, or sneeze Explosive onset of severe HA Systemic symptoms Fever, weight loss, rash, joint pain, etc 42 42

43 Indications for Neuroimaging-2 Sleep-related headache Awakening patient at night Present on arising consistently New or different severe headache, change in frequency or features Neurologic symptoms or signs Altered mental status, focal signs, movement disorder/tic or seizure like, visual changes, papilledema, asymmetric neuro findings 43 43

44 Indications for Neuroimaging-3 Secondary risk factors Immunosuppression, hypercoagulable state, neurocutaneous signs, rheumatic disorder, cancer, genetic disorder Tinnitus (bruit like-pulsatile by description) Cyclic symptom pattern (vomiting, HA, etc) especially if associated with other signs

45 Other Less Common Causes of Headaches in Kids Transition 45

46 Vascular Disorders Spontaneous intracranial hemorrhage Thunderclap headache Abnormal neurologic exam Ischemic stroke Sudden onset headache Abrupt change in neurologic function Usually unilateral (could mimic aura but not bilateral and <30 min.) and prolonged Sinus venous thrombosis Headache, focal neuro signs, seizures, papilledema, decreased level of consciousness

47 Trauma All cases of head trauma with progressive headache or altered mental statusà ED Post-traumatic headaches develop within 7 days (trauma, whiplash, etc). Often other symptoms (dizziness, mood, sleep disturbances, cognitive changes.) Most go away within 2 weeks or so. Return to activity should be slow After headache is gone Concussion center? 47 47

48 Substances Caffeine Alcohol Carbon monoxide Lead Thyroid meds Antihistamine/allergy meds Oral contraceptives Many others 48 48

49 System Diseases Metabolic Derangements & Endocrine Disorders Seizure Disorders Mitochondrial Disease Dental Disease Sickle Cell Disease Hypertension Rheumatologic Disease Psychiatric Disease 49 49

50 Transition 50

51 Evaluation of Headache in Kids HISTORY-single most important tool Parents and patient involvement is necessary for complete picture. Get detailed medical history in addition to a detailed history about the headaches. Think disease Think medicine related 51 51

52 Adapted From A.D. Rothner Semin Pediatr Neurol. 1995;(2): How many types of headaches does your child have? Onset of symptoms was? Associated events? Are the headaches increasing (or decreasing) in frequency or intensity? Have you noted triggers (initiating events)? What makes the headache better? (or worse) 52 52

53 From AD Rothner-2 Describe the headaches. Where are they located? What do they feel like? Do the headaches wake the child? Other symptoms with the headache (ie aura)? How does your child behave during the headache? (What does he/she do?) How long does the typical HA last? 53 53

54 Other important history Family Parents, siblings, grandparents, aunts, uncles. Social Conflict at school, home, depression, alcohol use in the home, weight changes (eating disorders) Pregnancy, sexual activity, abuse-sexual/physicao Life style Diary of headaches is often helpful Sleep, diet, fluid intake, exercise 54 54

55 Physical Examination Vitals, include BP, height, weight (plot on curves) Skin, oral membranes, Neurologic-focal signs, papilledema, etc 55 55

56 Other Testing Generally indicated by history and exam If increased ICP-neuroimaging/LP CSF studies 56 56

57 Transition 57

58 Management Schemes Change life style, especially adolescents Consider medication use Complementary Medicine (OMM) Preventive Therapy Biofeedback 58 58

59 Treatments S---sleep (regular and adequate) M---meals (3+regular, adequate fluids) A---activity (not excessive) R---relaxation (decrease stress) T---trigger avoidance (lack of sleep, stress avoidance, etc) 59 59

60 Drugs Acetaminophen mg/kg q 4-6 hours Ibuprofen 10 mg/kg q 6 hours Naproxen 5-7 mg/kg q 8-12 hours Can add anti-nausea meds 5-HT1 agonists (triptans) Rizatiptan 5-10 mg (can repeat x1 in 2 hr) max 15 mg/day (approved to 6 yoa) Zolmitriptan PO/nasal 2.5 mg-5mg per dose Can repeat x1 in 2 hours max of 10mg/day 60 60

61 Drugs- Triptans-continued Sumatriptan mg (max of 200 mg per day) Nasal 4-6 years: 5 mg 7-11 years: 10mg >12 years: 20mg safety and efficacy in adolescents Adult max+ 40mg/day SC dosage form available Almotriptan mg-may repeat x1 in 2 hours Maximum dose 25mg/day 61 61

62 Prophylactic Treatments Beta-Blockers Anti-Seizure Meds Valproic Acid Others Calcium Channel Blockers (Verapamil) 62 62

63 Prophylactic Meds- Antidepressants Amitriptyline (25mg/50mg per day) Nortriptyline Desipramine (more EKG problems) SSRI Suicidal tendencies Possible serotonin syndrome possible if mixed with triptans 63 63

64 Prophylactic Meds--- Cyproheptadine (antihistamine/ serotonin antagonist) also acts as appetite stimulant, may take 4-8 weeks for migraine prophylaxis, used from 6 yrs and up

65 References Pediatrics in Review, Volume 33, No. 12, December 2012 Uptodate-Headaches in Children Nelson s 19 th Edition Textbook of Pediatric Emergency Medicine; Fleisher, Ludwig, Heneetig, 5 th edition 65 65