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Headaches in Children. April 28 th , 2014 Chloé Corbeil (Thank you Dr. Orr!) . Clinical Scenario.

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    1. Headaches in Children April 28th, 2014 ChloéCorbeil (Thank you Dr. Orr!)

    2. Clinical Scenario A 10 year old boy is brought to your office by his mother. She is concerned that Ricardo is having recurrent headaches. They have been occurring off and on for 2 years. Upon further questioning, Ricardo’s headaches have been increasing over the past 2 months with him missing at least 3 days of school per week. Mom is very concerned that Ricardo has a brain tumour.

    3. Objectives • Discussion of the differential diagnosis of headaches • Pertinent clinical information that differentiates organic from non organic headaches • Management issues of headaches in pediatrics • Discuss the issues around school refusal

    4. « Physiciansshouldconsiderheadache as a symptomratherthan a neurologicdisorder »- PediatricClinics of NorthAmerica (Vol 47 Issue 3)

    5. Pathogenesis • The brain has NO pain receptors • Pain can be referred to the head from the following structures: • Intra/extra cranial blood vessels and sinuses • Cranial/spinal nerves • Basal meninges • Cranial/cervical muscles • Extra-cranial structures: nasal cavity, sinuses, teeth, mucous membranes, skin and subcutaneous tissues.

    6. Pathogenesis cont. • Headache can result from: • Traction on vascular structures within the head • Displacement of intracranial contents (abcess, tumoretc) • Sustained contraction of the head and neck muscles • Processes outside the head (sinuses, eyes, teeth etc) • Its all in the nerves… • Cranial circulation and supratentorial structures  travels via the trigeminal nerve  pain referred to the front of the head • Posterior Fossa  travels via the first three cervical nerves  back of the head and neck +/- ears and throat

    7. DDx: Headache • DOC! My head hurts!

    8. DDx: Headache • Tension-Type Headache (TTH) • Migraine +/- Aura • Cluster headache (rare before puberty) • Epilepsy • Head Trauma • Sinus headache • Ocular headache (glaucoma, astigmatism…) • Noncephalic infection • Vascular disorder (HTN, pheochromocytoma, hematoma) • Nonvascular intracranial disorder (neoplasm, infection, hydrocephalus…)

    9. DDx: Headache • And the list goes on… • Metabolic disorder (hypoxia, high altitude, sleep apnea, hypoglycemia) • Secondary to substance exposure (CO poisoning, nitrate, EtOH, analgesics abuse) • Associated with substance withdrawal (Alcohol « hangover », caffeine, narcotics) • Psychological (depression, school phobia)

    10. That is quite the differential diagnosis for a headache… But… • A THOROUGH history and physical exam will USUALLY suffice • Imaging and lab testing are rarely required • Don’t forget your RED FLAGS!

    11. RED FLAGS RED FLAGS for: • Headache • Vomiting • Psychological or behavioral signs • Other

    12. RED FLAGS 1. Headache • Recent onset • Increased severity and frequency • Morning or nocturnal occurrence • Awakens the patient from a deep sleep • Constant, daily • Lack of relieving or triggering factors • Lack of familial migraine history • Occipital or strickly unilateral location (in young children) • Associated with projectile vomiting • Made worse by straining, sneezing or coughing • Exacerbated or improved markedly by changing position

    13. RED FLAGS 2. Vomiting • Increased severity and frequency • Without nausea 3. Psychological or behavioural signs • Drowsiness and irritability • Change in eating habits • Anxiety • Mood Swings • Poor concentration

    14. RED FLAGS 4. Other • Neurologic abnormalities • Decreased visual acuity • Seizure associated with headache • Focal neurologic symptoms developing during a headache • Focal neurologic symptoms developing during the aura (other than classic symptoms) persisting or recurring during the headache • Age less than 6 yrs • Deceleration of linear growth

    15. Any Red Flags? • Ricardo, a 10 year old boy, is brought to your office by his mother. She is concerned that Ricardo is having recurrent headaches. They have been occurring off and on for 2 years. Upon further questioning, Ricardo’s headaches have been increasing over the past 2 months with him missing at least 3 days of school per week. Mum is very concerned that Ricardo has a brain tumour.

    16. Any Red Flags? Ricardo, a 10 year old boy, is brought to your office by his mother. She is concerned that Ricardo is having recurrent headaches. They have been occurring off and on for 2 years. Upon further questioning, Ricardo’s headaches have been increasing over the past 2 months with him missing at least 3 days of school per week. Mum is very concerned that Ricardo has a brain tumour.

    17. Quiz time – Two for one special • Are tension type headaches more common in adults or children? • How long do paediatric migraine episodes usually last? • 30 minutes • 1 hour • 4 hours • 2 days • Children don’t get migraines…

    18. Taking a History

    19. Physical Exam • Remember our DDx?

    20. Physical Exam – What to look for…

    21. Putting it all together…

    22. Headaches – Back to Basics

    23. Investigations

    24. But doctor! My son has a BRAIN TUMOR! • “Neuroimaging on a routine basis is NOT indicated in children with recurrent headaches and a normal neurologic examination” • Neuroimaging should be considered in children with and abnormal neurologic exam, the coexistence of seizures or both • Neuroimaging should be considered in children with ‘red flags’ on history

    25. PresentingFeatures of BrainTumors Most common first symptom • Headache (41%) • Vomiting (12%) • Unsteadiness (11%) • Visual difficulties (10%) • Education or behavioural problems (10%) • Seizures (9%)

    26. PresentingFeatures of BrainTumors 88%present with abnormal neurological signs • Papilloedema (38%) • Cranial nerve abnormalities (49%) • Cerebellar signs (27%) • Long tract signs (27%) • Somatosensory abnormalities (11%) • Reduced LOC (12%)

    27. And now for (almost) completely irrelevant trivia: • In which movie would you hear the line: « I do not envy the headache that you will have when you awake, but till then, sleep well and dream of large women. »

    28. Management • Once diagnosis of migraine or TTH has been made: reassure the patient and his/her family • Acute pharmaceutical management • Non-pharmaceutical prophylaxis • Pharmaceutical prophylaxis

    29. Management cont. Acute Management • Reassurance • Rest in quiet/ dark room (more for migraine) • Analgesia : • Ibuprofen: 10 mg/kg • Acetaminophen: 10-15 mg/kg • Sumatriptan (5HT-1 RA; emergency tx migraine) • Managing No/Vo

    30. Management cont. Non- Pharmacological prophylaxis • Migraines: • Avoid triggers (poor sleep, stress, caffeine, chocolate) • Exercise • Bio-feedback • Tension Headaches: • Eye exam: rule out refractory errors • Avoid triggers Pharmacological prophylaxis • Flunarizine: 5mg/day (non-selective CCB) • Propranolol: 2-4 mg/kg daily • Amitryptiline: 10-50 mg daily at bedtime • Trazodone: 1 mg/kd/d

    31. Back to ourfriend Ricardo… • During the course of the interview, it is revealed that Ricardo is struggling at school necessitating several parent-teacher discussions. The teacher finds Ricardo to be easily distracted and quite disruptive throughout the school day. Ricardo reveals that he misses school as much when he does not have a headache as when he does. He also reveals that he is having many interpersonal difficulties with his peers.

    32. SchoolRefusal • Characterised by: • Child’s emotional upset at the prospect of going to school • Absence of significant antisocial behaviour in the child • Parental awareness of and antipathy towards the problem * May jeopardise the child’s social, emotional and academic involvement

    33. Associated Disorders and Stressors • Anxiety • Bullying • Learning Disorders • Depression/Subclinical Depression (up to 50% children) • Autism Spectrum Disorders • Physiological symptoms: abdominal pain, headaches, diarrhea, dizziness • Social phobia, separation anxiety

    34. Quiz : School Avoidance What is the prevalence of school avoidance across primary and secondary school level? • 0.5% • 1% • 3% • 5%

    35. Bullying • In the United States • 10% of Children experienced extreme victimization • 80-90% of school children will face psychological and physical harassment that may be considered bullying

    36. The role of the pediatrician… • Identify the problem • Council parents, children and even school personnel regarding interventions and prevention • Screening for, treating or referring to psychiatrists or psychologist when mental comorbidities are present • Advocating for violence prevention and for the right of children to attend school and live in a safe environment

    37. Management Strategies Psychosocial Stressors • Cognitive Behavioural Therapy • Working with school staff, counsellors and parents in creating strategies to manage anxiety and coping with school attendance • Creating an attendance based plan • Working with relaxation training procedures • Regular discussion regarding violence and bullying at school • *There may be a role for pharmacological treatment (severe emotional disturbances)

    38. Merci!

    39. References Abu-Arafeh I, Razak S, Sivaraman B, Graham C. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies.Dev Med Child Neurol 2010; 52:1088. Annequen, D., Tourniare, B., Massiou, H. (2000). Migraine and Headache in Childhood and Adolescence. Pediatrics Clinics of North America, 47(3). Boes CJ, Black DF and Dodick DW. (2006). Pathophysiology and management of transformed migraine and medication overuse headache. SeminNeurol 26(2):232 Bouthius, D. and Lee, A., 2013. Approach to the Child with Headache. UpToDate. Retrieved April 20th, 2014. Dooley, J. (2009). The evaluation and management of pediatric headaches. Paediatr Child Health, 14(1), 24-30. Forsyth, R and Farrel, K. (1999). Headache in Childhood. Pediatrics in Review, 20(2), 39-45. Glew, G., Rivara, F. and Feudtner, C. (2000). Bullying: Children Hurting Children. Peds in Review, 21 (6), 183-190. Heyne, D., King, N., Tonge, B., Coope, H. 2001. School Refusal: Epidemiology and Management. Paediatr Drugs, 3(10), 710-732. International Headache Society, Classification ICHD-II. Retreived April 24th, 2014. Lewis, D. 2002. Headaches in Adolescents and Children. Am Fam Physician, 65, 625-636 Wilne, S., Ferris, R.S., Nathwani, A and Kennedy, C. (2006). The presenting features of brain tumors: a review of 200 cases. Arch Dis Child, 91, 502-506.

    40. A little extra reading…. • DDxheadache –Organic vs. Inorganic

    41. Migraine without Aura • At least 5 attacks fulfilling criteria 2-4 • Headache attacks lasting 1-72 hours • The headache presents at least two of the following characteristics: • Unilateral, bitemporal • Pulsating quality • Moderate or severe intensity • Aggravation by physical activity • During the headache at least one of the following: • Nausea or vomiting • Photophobia and phonophobia

    42. Migraine with Aura • At least two attacks fulfilling criteria 2 • At least three of the following four characteristics • One or more fully reversible aura symptoms indicating focal cortical or brain stem dysfunction • The aura symptom develops gradually over more than 4 minutes or two or more symptoms occur un succession • No aura symptoms lasts more than 60 minutes • Headache follows the aura with a free interval of less than 60 minutes (it may also begin sometimes before or simultaneously with the aura)

    43. Prenksy Criteria for Diagnosing PediatricMigraines Episodes Characterized by at least 3 of the following: • Hemicranial Pain • Throbbing or pulsatile character to pain • Associated with abdo pain, n/v • Complete relief after rest • Visual, sensory and or motor aura • Family history of migraine in first –degree of relatives

    44. Medication Overuse Headache • Headache present on ≥15 days a month • Regular overuse for more than three months of one or more acute/symptomatic treatment drugs • Ergotamine, triptans, opioids, or combination analgesic medications on ≥10 days a month on a regular basis for more than three months • Simple analgesics or any combination of ergotamine, triptans, analgesic opioids on ≥15 days a month on a regular basis for more than three months without overuse of any single class alone • Headache has developed or markedly worsened during medication overuse