Headaches Practical approach

1. HeadachesPractical approach Dr Maltby

2. Chronic Headache • Migraine • Tension headaches/chronic daily headaches • Teeth/Nocturnal grinding • Sinus congestion • Visual • Sleep apnoea • Benign Occipital Epilepsy • BIH • Raised intracranial pressure

3. When to scan • Very young children • Change in the character of headaches • History suggestive of raised ICP • Focal neurological Signs • Papillodema – not optic detrusum • Headache with erratic vomiting • FH or anxiety of IC lesion • BIH with optic nerve views

4. Mausley Study • Very old study 1998 • Looked at children with CNS tumours mode of referral and the symptoms • Majority DID NOT have symptoms classically of raised ICP • Majority DID NOT have focal neurology • Majority had frequently been seen by GP paediatricians and even a paediatric neurologist

5. Conclusions • Falsely reassured by normal examination • Signs of ICP are great but don’t help • Change in character in under 5 • School failure in over 5

6. Migraine • Episodes headaches relief with sleep • Vomiting • Visual disturbance- specific • Pallor • FH • Motion sickness • Neurological symptoms vary • Between times pain free

7. Management • Examination normal • Scan if under 5 • Advice about treating the acute attack • Isolating triggers avoidance if possible • Multiple

8. Triggers • Dietary – dairy, citrus, tomatoes, blackcurrant, fizzy drinks – J2O • Sleep – excessive weekend lyins or sleep overs • Excitement • Stressed out • Busy life

9. Busy lives • After school clubs • Sibs after school clubs • Weekend activity • Sleep overs • Home work – plans/supervision • Friendships • Sport activities • Rushing mothers

10. Management of acute attack • Immediate analgesia- emergency protocol • Write to the school for their support • Ibrufen, Migraleve • If vomiting Migraleve • Very rare to need Sumitryptin • Monitor school attendance maybe late attendance better than none

11. Preventive management • Depend on the frequency school attendance • Diet exclusion • Recognise triggers • Pziotifen • Others treatments- Topiramate, Epilum,Gabapentin, Amitriptyline

12. Chronic daily headache • Teenagers • High achievers • Driven from within not by school/parents • Lots of mates- squabble or miss no mates • Area of stress in family home • Not helped by analgesia • Never wake with headache but have it at night • Most difficult to manage

13. ManagementGeneral advice • Fluid intake • Regular meals- diet restrictions • Regular exercise • Regular sleep patterns – lying in! • TV and computer usage • Analgesia usage • Normalising life • After school clubs and in sibs • Avoid asking” do you have a headache” • Family attitude to illness

14. Explanation • Stressy teenagers learn to relax- pilartes • Advice about studying • Driven from within • Learn to live with it

15. Treatment strategies • Dietary exclusion – formally not by diary • Diary – shocking what they eat • Exclude for 6 weeks: • Diary products • Citrus/Apples in any form • Tomatoes and ketchup • Fizzy drinks • Blackcurrant drinks • Chocolate • Marmite • Anything else you can think of especially if the love them • Replace one thing every 4 days if there was a response

16. Medication • Diet fails or the child cheats or refuses • Explanation of pain modification the pain is there but the response is different • Trail of Pziotfen ONLY at night – for at least 6 weeks • Topiramate • Gabapentin • Epilum

17. Alternative treatements • Butterbur • Migraine support group • Headache clinics • CAMS

18. BIH • DO not diagnosis this unless confirmed papillodeama and optic nerve swelling on MRI • Reproducible reduction in visual acuity • Formal visual fields assessment is poor even in teenager • Child has a risk factor – obesity and tetracycline usage

19. Diagnosis • Raised pressure on opening at LP • Not under GA straightened legs • Pressure above 20 • Therapeutic and diagnostic procedure so reduce pressure to 20 if over 40 then halve it • Dramatic response to LP in terms of treatment

20. Pitfalls • Repeated LP • Refusal to allow it without a GA • Symptoms from LP confuse the picture • Side effects from the Diamox • Evidence that evolves residual chronic daily headache • Bolt monitoring

21. Questions?

22. Hard work

23. Fits Faints and Funny turns

24. Noah • 18 months • Three episodes when his mother says he is found on the floor unresponsive floor and jerks lasts about 30mins but father thinks less. • Preceded by a cry • After he appears confused and inconsolable • EEG performed by the SHO after being seen in A/E- normal • ECG normal QTc 0.42sec • 24hr ECG normal • FH father used to do this as a child and was treated with Phenytoin • Comes to discuss if they should give a trail of anticonvulsant

25. Ellie • 12 years of age • C/O fit at school • Fat lasting 5 minutes witness by the first aider (whose sister used to have fits) • Called 999 by the maths teacher was sick and confused afterwards • In A/E now feeling better fully conscious a slight headache • B?S by paramedics 6.5 • PMH febrile convulsion resulting in an PICU admission for 24 hours given rectal diazepam  that mother still carries • FH Mother has epilepsy on Tegretol • Exam normal • No focal signs to find • One café au lait  spot • Referred to you asking if they could attend first fit clinic and an EEG has been organised

26. Part two - clinic • Further episode occurred during home tec and at home witness by her older sister • School refuse to have her back unless “some things is done” • Mother is sleeping in her bedroom on the floor • EEG –non specfic changes has occasional spikes

27. MAX • 4 years of age- 8 daily episodes cries sits down goes rigid eyes roll back lasting 2mins then confused afterwards for a bout 30mins. • Described as pale • Max says he feels dizzy before hand. • Neurodevelopmental normal • No other reported problems – absence episodes reported by the nursery but not noted at home • PMH – sinus bradycardia as neonate seen by Cardiologist at GOS happy with him • Examination normal HR 70 nil else • Echo normal • ECG normal • Normal QTc -0.44sec • 24hour tape mum went to anyway not cancelled

28. Differential diagnosis of a seizure • Syncope-         Vasovagal •                         Cardiac causes- cardiomyopathy/prolonged QTc • Breath holding • Reflex anoxic seizures/ Reflex anoxic syncope • Psuedo sezuires • Emotional syncope • Valsalva/ constipation • Stereotypical behaviours • Tics • Gratification habits • Basilar migraine • Paroxysmal spasmodic torticollis • Benign paroxysmal vertigo

29. TAKE A HISTORY THE EVENT AND THE RUN UP AND AFTER. • If your not sure adopt watchful waiting DO NOT order an EEG unless you think it will give you information and interoperated the information with the clinical case • Give advice

30. What are the risk for a reoccurrence after one seizure? After two seizures? • What should you tell them to do at school? • Whats the advice regarding swimming? • Whats the advice about sleeping arrangements? • Whats to do about TV and computer games? • Any other advice? • You reg wants to give them Midazolam prescribe it?

31. Is the episode a seizures? • What’s the cause of the seizure? • Is this epilepsy? • What is the cause of the epilepsy? ---------- NOW think EEG • Classify epilepsy into a syndrome?

32. www.stars.org.uk

33. www.epilepsy.org.uk/info

34. Epilepsy advice and information • What is epilepsy? • Caring for a baby or young child when you have epilepsy: a detailed guide • Children • Depression and epilepsy • Developing epilepsy in later life • Disability Discrimination Act (UK) • Driving and epilepsy • Education • Entitlements and benefits for people with epilepsy • Epilepsy and learning disabilities • Epilepsy and Travel abroad • Epilepsy information for prisons • Epilepsy, osteoporosis and osteomalacia • Flu and epilepsy • Getting a diagnosis • Identity jewellery • Inheritance • Living with dificult to control epilepsy • Me and my dad