Pediatric Neurology Quick Talks

Headache
Michael Babcock
Summer 2013

Scenario

7 yo boy
Headaches for 4 months
Headaches last 90 minutes
Grabs the front of his head when it hurts
Has about 1 headache a week, vomits with some of the headaches
Continues to do well in school, no vision complaints

Causes of headache

Primary
Migraine
Tension-type
Cluster
Paroxysmal hemicrania
SUNCT
Trigeminal neuralgia (not
common in kids)
Chronic daily headache

Secondary
Medication overuse
(rebound)
head/neck trauma
Vascular disorder SAH,
AVM, vasculitis, CSVT
High ICP / Low ICP
Tumor
Infection
CNS
Other infections

History

Headache quality, severity, location, laterality, onset, time course

episodic and similar or progressive/changing
Associated symptoms systemic symptoms, fever, personality changes,
seizures
Preceding symptoms aura, gradual/rapid onset
Exacerbating features migraines worse with activity; worse with laying
or nocturnal or with cough/straining signs of elevated ICP; worse with
standing signs of low ICP.
Medical history NF1, Sturge-weber, connective tissue disorder, Sickle
cell, immunocompromised.

Exam

Vitals fever, ICP signs

Good neurologic exam
? Altered mental status
Abnormal eye movements
Visual field testing
Fundoscopic exam
Focal weakness
UMN signs
Abnormal gait

Papilledema (normal to severe)

Work-up

Imaging
Trauma
Associated seizures
AMS
Abnormal neurologic exam
Historical features thunderclap
headache, persistently lateralized,
progressive course, shunt, change in
pattern/type, occipital headache
Signs of elevated ICP
Considerations:
no family history of migraine
< 1 month of headache
Young age of onset
Prior to LP

CSF analysis
Pseudotumor (IIH)
Accurate recording of pressure,
in lateral decub position must
extend LE's.
Meningitis
Meningismus
Fever
New seizures
AMS
immunocompromised
SAH
Thunderclap headache

Migraine

Affects 7% of all children

Causes $1-17 billion in lost productivity
Accounts for 10 million physician visits/year in U.S.

Migraine Classification

Pediatric migraine with aura

At least 2 attacks fulfilling B.
At least 3 of the following
One or more fully reversible aura
symptom indicating focal cortical
and/or brainstem dysfunction
at least 1 aura developing
gradually over > 4 min or > 2
aura symptoms occurring in
succession
No auras lasting > 60 minutes
Headache no more than 60
minutes after aura

Migraine treatment Life-style modification

Sleep don't vary by more than one hour on school/weekend nights

Exercise regular exercise, but over-exercise can cause headache
Mealtimes 3 meals daily, don't skip meals
Hydration carry water bottle school excuse to carry and go to bathroom
Stress stress reduction techniques
Caffeine moderation or stop
Analgesic overuse
Don't use OTC pain relievers more than two-three times weekly
Opiates can also cause this
To relieve headache have to break cycle, stop medication, headache
worse for 2-3 weeks, then better.

Migraine Medications - Preventative

Cyproheptadine AAN PP insufficient evidence histamine and

serotonin antagonist with Ca-channel blocking properties; SE weightgain and sedation. Can be OK for younger, non-overweight children.
Beta-blockers conflicting evidence. SE asthma, DM, orthostatic
hypotension, depression, not good for athletes
Amitryptaline (TCA's) depressino/affective disorder often co-morbid
with migraines. SE QT prolongation get EKG, behavior change
Ca-channel blockers Verapamil good for hemiplegic migraine
AED's
Topamax SE weight loss, cognitive change, sedation
Depakote SE weight gain, PCOS, teratogenic; need CBC/LFT
monitoring
Keppra consider because low SE profile
Gabapentin SE sedation

Migraine Medications Abortive

Naproxen (Aleve) 10-20mg/kg/d div Q8H. For patients over 30kg. Can give 1-2
tabs at onset, 1 more tab in 8 hours.
Motrin
Fioricet (acetaminophen/butalbital/caffeine) or fiorinal good for rescue but risk of
dependance, overuse probably best not to give outside ED.
Anti-emetics Phenergan, Reglan, Compazine can give benadryl to help with
sleep/extrapyramidal effects
Triptans Sumatriptan (PO, SC, IN) Adult oral PO dose is 25-100mg at onset,
max 200mg/day PO. No dosage recommendations for children in packet. SE-- heart
vasospasm, MI, arrhythmias, HTN, stroke, seizure, rebound headaches;
chest/jaw/neck pain.
Ergots nasal DHE (Migrinal nasal spray) 1 squirt in each nostril SEchest
pain, nausea, cannot use within 24 hours of triptan
In ED hydration with NS, Magnesium, Depakote, Ketorolac if not medication
overuse, compazine, benadryl, steroid

References

http://eyewiki.aao.org/Papilledema
http://www.kellogg.umich.edu/theeyeshaveit/acquired/papilledema.html
AAN Practice parameter migraines
Maria, B. 2009. Current management in child neurology. People's medical
publishing house.