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4shared.

HEADACHE AND SEIZURES


Dr. Bernadette Terencio

HEADACHE IN KIDS
Types:

Primary

Secondary

Headache Syndromes
Evaluation
Management

Pharmacologic

Nonpharmacologic

PAIN SENSITIVE STRUCTURES OF THE HEAD:

The skin, its blood supply and appendages

Muscles of the head and neck

Great venous sinuses and their tributaries

Dura matter at the base of the brain and dural


arteries

Intracerebral arteries

Cervical nerves

Cranial nerves V, VI and VII

February 1, 2012

Acute Localized

Sinusitis

Otitis

Ocular abnormality

Dental disease

Trauma

Occipital Neuralgia

TMJ disorder

Recurrent

Vascular Disease

Intoxication

MELAS

Postseizure

Hypoglycemia

Exertion

Chronic Progressive

Tumor

Pseudotumor

Brain abscess

Subdural hematoma

Hydrocephalus

PRIMARY HEADACHES

Migraine

Tension-type

Cluster
SECONDARY HEADACHES

C
Congenital anomalies (HCP, Arnold-Chiari)

I
Infections (meningitis, abscess)

T
Toxin (cocaine, amphetamine)

T
Trauma (subdural, epidural)

E
Endocrine (hypoglycemia)

N
Neoplasm (brain tumor, leukemia)

D
Degenerative disorder (Alexanders
disease)
V
Vascular (aneurysm, AVM, coagulation
disorder)
M
Metabolic (hypoxia, dehydration, fever)
Secondary Headache
(Temporal Presentation)
Acute Generalized

Systemic infection

CNS infection

Toxins(lead,CO)

Postseizure

Electrolyte imbalance

Hypertension

Hypoglycemia

PostLP

Trauma

Embolism

Vascular thrombosis

Hemorrhage

Collagen disease

Exertion

mcps

Shunt Malfunction

**FACES PAIN SCALE (Pediatrics)**

**Migraine happens in children as early as 5 years old;


usually relieved by rest, sleep and medications**
** At nighttime, Rhythym becomes shallow, dec O2, inc CO2
**Inc CO2= potent vasodilator
**Dec O2= potent vasoconstrictor

IHS MIGRAINE CLASSIFICATION


1.1 Migraine without aura (common migraine)
1.2 Migraine with aura (classic migraine)

1.2.1 Migraine with typical aura

1.2.2 Migraine with prolonged aura

1.2.3 Familial hemiplegic migraine

1.2.4 Basilar migraine

1.2.5 Migraine aura without headache

1.2.6 Migraine with acute onset aura

1.3 Ophthalmoplegic migraine

1.4 Retinal migraine

1.5 Childhood periodic syndromes that may be


precursors to or associated with migraine

1.5.1 Benign paroxysmal vertigo 1.5.2 Alt.


hemiplegia
MIGRAINE ASSOCIATED SYMPTOMS
(Lewis and Winner, 2001)

Prodromal (hours or day in advance)

Mood changes

Irritability

Euphoria

Increased thirst

Increased urination

Fluid retention

Food craving (high carbohydrate food)

Yawning, sighing
The headache

Gradual onset

Escalation over minutes to hours

Lasts 2-72 hours

Frontal, bitemporal, retro-orbital, unilateral

Pounding, pulsing, throbbing

Intensity increased by activity


Autonomic symptoms

Nausea, vomiting, anorexia

Peroumbilical abdominal pain

Diarrhea

Pallor

Phonophobia/Photophobia

Desire to sleep

Cool extremities

Periorbital discoloration

Goose flesh

Increased or decreased blood pressure

Syncope
Miscellaneous

Motion sickness

Sleep walking

Recurrent abdominal pain

Migraine Auras

Binocular visual impairment with scotoma

Distortion or hallucinations

Micropsia

Macropsia

Matamorphopsia

Teleopsia

Monocular visual impairment or scotoma

central scotomas

Spotty scotomas

Hemianopia

mcps

Clinical Approach to the Child Presenting with


Headache

Key information required from Medical History

Temporal pattern of headache

Duration, frequency, location, quality and


severity of pain

Exacerbating/ alleviating factors

Response to treatment

Aura

Past hx of headache

Changing quality/location/severity of pain

Family history of headache

Toxic exposure, intake of drugs

Trauma

Associated symptoms/Neurologic
symptoms

Sinus or dental pain,nasal discharge,facial


pain

Past medical history


Required Elements of a Thorough Physical and
Neurologic Examination

Vital signs

Blood pressure, pulse, respiration

General physical examination

Nuchal rigidity, TMJ, dental, lymph node


tenderness,etc

Funduscopic examination
Cardiopulmonary examination
Skin rashes, petechiae, ecchymosis, needle tracts
Hepatosplenomegaly
Neurologic exam
Imaging for the Evaluation of Headache

High priority

Chronic progressive pattern

Acute headache

Worst headache of life

Thunderclap headache

Abnormal neurologic examination

Focal neurologic symptoms

Presence of VP shunt

Presence of neurocutaneous syndrome

Age < 3 years

Moderate priority

Headache or vomiting on awakening

Unvarying location of headache

Meningeal signs

Spectrum of Diagnoses for Headache at Miami


Childrens Hospital Emergency Department
Viral illness
39.2%
Sinusitis
16%
Migraine
15.6%
Post-traumatic Disorder
6.6%
Viral Meningitis
5.2%
Streptococcal Pharyngitis
4.9%
Tension
4.5%

Most Frequent Diagnoses for Headache at a ShortStay Unit


29%
21%
14%

31%

Fasheh Y. et.al.,
Pediatrics, 1999

57%
(39%)
(9%)
(9%)
18%
9%
2.6%
1.3%
1.3%
1.3%
1.3%
Lewis DW et.al.,
Headache, 2000

Combination Analgesic
Fioricet
Butalbital+Acetaminophen+Caffeine

Esgicplus

Axocet

Acute Treatment Strategies: Moderate to Severe


Migraine

5-HT1 agonists (triptan)

Ergotamine (dihydroergotamine)

Nonsteroidal anti-inflammatory drugs

Antiemetics

Opioid analgesic
Preventive Migraine Therapy

Acute Headache in Pediatric Emergency Department


Upper Respiratory Tract Infection
Viral Infection
Sinusitis
Strep pharyngitis
Migraine
Viral Meningitis
Brain Tumors
Shunt Malfunction
Intracranial Hemorrhage
Post-ictal Headache
Post-concussive Headache
Undetermined cause

10mg/kg

Pratt-Cheney JL et.al.,
Pediatric Emergency Care, 1997

Infection
Tension
Migraine
Non-specific

Naproxen

2%

Agent
Cyproheptadine
HS
Propranolol
BID
Tricyclics
Amitriptyline
10mg HS
Nortriptyline
10mg HS
Divalproex sodium
125mg QD

Initial Dosage
2 mg BID or 4 mg
1mg/kg up to 10mg

0.25mg-0.5mg/kg to
0.25mg-0.5mg/kg to
10mg/kg to

Nonpharmacologic Treatment of Migraine


Education
Biofeedback
Stress management and relaxation exercises
Elimination of triggers
Sleep regulation
Exercise

Drug Therapy for Headaches: Abortive Therapy

Drug

Ergotamine

Dihydroergotamine

Isometheptene

Triptans

Chlorpromazine,promethazine

Metoclopromide

Lidocaine (4%)

Mechanisms

Vasoconstrictor

Vasoconstrictor

Vasoconstrictor

Serotonin agonists

Antiemetic, sedative, adrenergic

Antiemetic

Local anesthetic

Acute Treatment Strategies: Mild to Moderate


Headaches

Simple analgesics
Dosage

Acetaminophen
15mg/kg

Ibuprofen

mcps

1010mg/kg

Migraine Triggers
FOODS

Ripened cheeses

Chocolate

Vinegar (except white vinegar)

Sour cream, yogurt

Nuts, peanut butter

Hot fresh breads, doughnuts

Lima beans, pea pods

MSG

Bananas

Pizza

Permented sausages, balogna, pepperoni,


hotdogs

Caffeine

Food dyes

ODORS

Perfume

Gasoline

Various food odors

STRESSES

School work

Excess number of extracurricular activities

Relationships

Disruption of lifestyle
Feeling bummed out or sad all the time

SUCCESSFUL MANAGEMENT OF PEDIATRIC HEADACHE

Reassure patient and parents there is no central


nervous system lesion.

Educate patients and their parents about the


pathogenesis and natural history of migraine.

Establish realistic goals for treatment according to


age.

POSSIBLE CAUSES OF SEIZURES IN ADULTS


Young adults
Head trauma
Alcoholism
Brain tumor
Older adults

SEIZURES
Seizure

An occasional excessive and disordered discharge


of nerve tissue
Manifestation of transient hypersynchronous
abnormal neuronal behavior

Brain tumor
CVA
Metabolic disorders
Alcoholism

Why Classify?

Definition
Seizure transient manifestation of abnormal
hypersynchronous discharges of cortical
neurons

Facilitate communication among professionals


Facilitate communication between physician and
patient
Aid diagnosis
Rational prescribing of AEDs based on accurate
diagnosis of seizure type
Prognosis

Epilepsy disorder characterized by the


occurrence of at least 2 unprovoked
seizures

Epileptic syndrome a disorder consisting of a


cluster of signs and symptoms plus its typical
EEG
International League Against Epilepsy (ILAE)
classification of Seizure Type
Mechanism of Seizure Generation
Pathophysiology of Epilepsy

Cellular level

Sodium channels

Calcium channels

Potassium channels

Synaptic level

Glutamate (excitatory)

GABA
(inhibitory)

Sodium currents/channels

The firing of an action potential is accomplished


through the NA channels

ACTIVE STATE channels allow INCREASED influx


of sodium into the cell

POSSIBLE CAUSES OF SEIZURES IN YOUNG PEOPLE

Infant
Genetic
(0-2 years old)
Hypoxia
Congenital Anomalies

Child
(2-12 years old)
Adolescent
(12-18 years old)
use/withdrawal

mcps

Head trauma
Acute Infection
Head trauma
Drug and alcohol

I. Partial seizure
A. Simple partial seizure (consciousness not impaired)
B. Complex partial seizure (with impairment of
consciousness)
C. Partial secondarily generalized
II. Generalized seizures
(bilaterally symmetrical and without local onset)
A. Absence seizures
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic-clonic seizures
F. Atonic seizures (astatic)
III. Unclassified epileptic seizures
(inadequate or incomplete data)
The ILAE Classification of Epilepsies and Epilepsy
Syndromes Shorvon, 2000
Simple Partial Seizure and Complex Partial Seizure
Impaired Consciousness

The inability to respond normally to exogenous stimuli


by virtue of altered awareness and/or responsiveness

Responsiveness

The ability of the patient to carry out simple

commands or willed movements

Awareness

refers to the patients contact with events


during the period in question and its recall

PARTIAL SEIZURE
Abnormal flow of electrical discharge from a specific or
single focus
Simple Partial Seizures

With motor symptoms

Focal motor without march

Focal motor with march (Jacksonian)

Versive

Postural

Phonatory (vocalization or arrest of speech)

Special sensory symptoms


Somatosensory
Visual
Auditory
Olfactory
Gustatory
Vertiginous
Epigastric sensation
Pallor
Sweating
Flushing
Piloerection
Pupillary dilatation
Apnea
Arrhythmias/bradyarrhythmia
Chest pain
Cyanosis
Erythema
Genital sensations/orgasm
Hyperventilation
Lacrimation
Miosis/mydriasis
Palpitations
Pilomotor excitation
Tachycardia
Urinary urgency/incontinence
Vomiting

With psychic symptoms


Dysphasic
Dysmnesic (dj vu, jamais vu, memory recall,
memory gaps/amnesia)

Cognitive (dreamy states, distortions of time


sense)

Affective (fear, anger, sadness, pleasure, sexual


emotion, emotional distress

Illusions (macropsia)

Structured hallucinations (music, scenes, visual,


auditory, olfactory)

Other (change in reality, depersonalization,


feeling of a presence (as if someone is
nearby), forced thinking, distortion of body
image)

COMPLEX PARTIAL SEIZURE

Appears to be in a dream like state.

Unaware or unresponsive to questioning

May perform unusual actions such as picking of


clothing's, grimacing, contorting to one side,
chewing

mcps

Feel confused for several minutes


No recollection of the event

Automatisms

More or less coordinated adapted involuntary


motor activity occurring during the state of
clouding of consciousness either in the course of,
or after an epileptic seizure, and usually followed
by amnesia for the event

Masticatory or oropharyngeal automatisms

Automatisms of mimicry, expressing the subjects


emotional state (usually of fear) during the seizure

Gestural automatisms directed toward either the


subject or his environment

Fumbling with the clothes, scratching, and other


complex motor activity

Ambulatory automatisms

Verbal automatisms

Partial

Secondarily Generalized
Simple evolving to GTC
Complex evolving to GTC
Simple evolving to complex evolving to GTC

PARTIAL EPILEPSY with secondary GENERALIZATION

Starts off as simple seizure which later evolves into


generalized seizure
Generalized Seizures

Begin throughout both hemispheres, more or less


simultaneously

Do not have localized onset

Reflect generalized disturbance of cortical function

Generalized Tonic Clonic


Generalized Clonic
Generalized Tonic
Absence
Myoclonic
Atonic

Generalized Tonic Clonic Seizure

May cry out or gasp, fall down, become rigid

Muscle may jerk, breathing becomes shallow

May lose bladder and bowel control

May drool, bite the tongue or lips and may turn


blue

Post ictal -maybe confused, drowsy, sleep for a


while or have headache
Absence Seizure
EEG : 3hz Spike Wave
Precipitated by: Hyperventilation
Myoclonic Seizures

Brief jerks of whole body or individual muscle


groups, usually without impairment of
consciousness

Lasts 2-10 seconds


Atonic Seizures

Drop attacks: sudden loss of tone

Relatively brief (5-30 seconds)

Generalized spike or sharp wave (with or


without a slow wave), generalized slow wave, or
diffuse background attenuation

Seizure First Aid for Generalized Convulsions


WHAT TO

DO:
Lay the patient on the floor.
Place something soft and flat under the head.
Loosen tight clothing around the neck.
Turn the head gently toward one side to prevent
choking.
Remove all sharp objects out of the way.
Time the seizure.
Reassure the patient as he regains
consciousness.

WHAT NOT TO DO:

Dont restrain.

Dont put anything in the mouth.


When do you bring a patient to the emergency room?

First seizure

Normal breathing does not start once the


shaking stops

Presence of injuries

When seizure happened in the water

When the patient has diabetes, pregnancy,


heart disease

Prolonged seizures ( more than 5 minutes


without signs of stopping)

Another seizure starts after the 1st one

Noisy respiration once the seizure stops

Other signs that something else is wrong


Criteria for starting antiepileptic drug therapy

Diagnosis of epilepsy must be firm

Risk of recurrence of seizures must be sufficient

Seizures must be sufficiently troublesome

Types of seizures

Frequency of seizures

Severity of seizures

Timing of seizures

Precipitation of seizures

Good compliance must be likely

Patient has been fully counseled

Selection of an Antiepileptic Drug: Factors to


Consider

Control of Seizures

Tolerability

Pharmacokinetic properties

Patient Characteristics

Drug interactions

Cost

1910 PHENOBARBITAL
- initially was used to induce sleep
- later found to have anti-seizure properties

1940 PHENYTOIN
- found to be effective in the treatment of
epilepsy major first line AED for partial and
secondarily generalized seizure

mcps

1968 CARBAMAZEPINE
- initially approved for the treatment of trigeminal
neuralgia
- 1974 later approved for partial seizures

1958 ETHOSUXIMIDE
- first choice for Absence seizure without
generalized tonic-clonic seizures

1960 (Europe) 1978 (US) VALPROIC ACID


- initially approved for the treatment of primary
generalized epilepsies neuralgia
- 1990 approved for treatment of partial sz

1990s NEWER AEDs


- good efficacy, fewer toxic toxic effects, better
tolerability

Pharmacologic Properties
Phenobarbital

Most commonly prescribed AED of the 20th century

A very potent Anti-convulsant because of its broad


spectrum of action

Partial, generalized, status epilepticus

Mechanism of Action

enhances GABA receptors

Metabolism Liver
Main advantages

Highly effective

Cheap drug

OD or BID dosing

CNS side effects

Hyperactivity (behavioral)

Effect on IQ (cognitive)

Sedation

Phenytoin

Main advantages

potent broad spectrum anti-epileptic drug


o
partial, generalized, status epilepticus

Highly effective and cheap antiepileptic drug

Not a generalized CNS depressant

OD to BID to TID dosing

Mechanism of action

Inhibits rapid firing of Na+ Channel

Metabolism Liver
Main disadvantages

CNS and Systemic side effects

Causes : ataxia, nystagmus, N/V congenital


malformation

coarse facial features

History of Anti-Epileptic Drugs

Carbamazepine

Major first line AED for partial seizure and

generalized seizure
Initially used for Trigeminal Neuralgia
Highly effective and well-tolerated

Mechanism of Action

Inhibits rapid firing of Na+ Channels


Metabolism Liver
Main disadvantage

Transient adverse effects on initiating therapy

Dose related adverse effect :

Dizziness, diplopia,nausea, ataxia and blurred


vision

Rarely : Steven Johnson syndrome

Valproate

Main advantages

Drug of choice for primary generalized


epilepsy

Approved treatment of partial seizures

Absorbed almost completely after oral


ingestion
Absorption not affected by food
Lack of epoxidation renders the drug
metabolism immune to impairments of liver
function
Partial and secondarily generalized seizure

Mechanism of action

Inhibits rapid Na+ firing

Interacts with Ca++ channels

Main disadvantages

Mechanism of Action

Inhibits rapid firing of Na+ channels

Inhibits Ca++ channels

In high doses: GABA enhancers

Metabolism Liver

Main disadvantages

Cognitive effects

Weight gain, tremors and hair loss

Potential for severe hepatic disturbance in


children

Gabapentin

Main advantages

Lack of side effects (especially) low dose

Good pharmacokinetic profile

Drug of choice in patients with liver problem

Main disadvantages

Lack of therapeutic effect in severe cases

Seizure exacerbation

Lamotrigine

Main advantages

Effective for partial and secondarily


generalized tonic-clonic seizure, primary
generalized seizure

well-tolerated

Mechanism of action

Inhibit rapid firing of Na+

Inhibit glutamate release

Metabolism Liver

Main disadvantages

High instance of rash (occasionally severe) in


rapid titration

other side effects


o
Headache, somnolence
o
GI disturbance, psychosis

Oxcarbazepine

Main advantages

Better tolerated and fewer interactions than


with carbamazepine

mcps

25% cross reactivity with carbamazepine


Higher incidence of hyponatremia than with
carbamazepine
Other side effects:
o
Somnolence, headache
o
Dizziness, weight gain
o
GI disturbances

Topiramate

Main indications

Adjunctive or monotherapy in partial and


secondarily generalized seizures

Also for Lennox-Gastaut Syndrome and


primary generalized tonic-clonic seizures

Alternative treatment for infantile spasms

Mechanisms of action

Blockade of sodium channels

Enhancement of GABA-mediated chloride


influx

Modulatory effects of the GABAA receptor

Actions at the AMPA receptors

Metabolism and excretion

Mainly renal excretion without metabolism

Side effects
Dizziness
Paresthesias
Weight loss
Tremors
Depression
Amnesia
Hyperactivity
Mental dullness

Irritability

---------------------------------THE END-----------------------------------**Italicized were just additional notes**


Accdg to Dr. Terencio, just study her lecture.
25 points will be from these topics
Thanks. God bless everyone.