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Welcome Applicants!

Welcome Applicants!. Morning Report: Thursday, December 8th. The Head CT…. The MRI…. Headaches. When to reassure and when to worry…. Question #1.

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Welcome Applicants!

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  1. Welcome Applicants! Morning Report: Thursday, December 8th

  2. The Head CT…

  3. The MRI…

  4. Headaches When to reassure and when to worry…

  5. Question #1 • A 12 yo female presents to the ED with a 1 ½ day h/o severe, throbbing right-sided frontemporal head pain. It necessitated her staying home from school today. She has had similar HAs in the past. She also c/o associated nausea, vomiting and sensitivity to light. Sleeping helps but has not gotten rid of this HA.

  6. Question #2 • An 11 yo male presents to the ED with recent onset of an extreme, nonthrobbing, deep pain in and around his right eye. He has also started to notice that the pain is spreading to the right side of his face. There has been no h/o trauma to that eye or side of the face. Mom says that his face appears more flushed than usual, and his right eye appears swollen and watery.

  7. Question #3 • A 9 yo female presents to her PCP with a month h/o recurrent HAs. She says it feels like there is a “tight rubber band” around her head. Mom has received a phone call from the school almost daily around 2pm regarding these HAs. Ibuprofen and rest seem to relieve the HAs. Mom is concerned that she has missed so many afternoons of school, which may affect her ability to get into Harvard.

  8. Question #4 • A 13 yo female with h/o migraines presents to the PCP with c/o increasing HA frequency. She reports that the location and severity have not changed. Instead of getting headaches once every 2 weeks, however, she is currently getting them daily. She was initially taking 200mg of Ibuprofen every 4-6h for her HAs, but that did not provide her with sufficient relief. She then switched to Excedrin Migraine and currently takes 2 pills about every 8 hours.

  9. Question #5 • A 5 yo male presents to the ED with a three week h/o HA. It started after a minor fall on the playground and has gotten worse despite attempts to treat with both Tylenol and Ibuprofen. Mom also comments on his “unluckiness,” as he recently acquired a GI illness which has caused him to vomit frequently and not sleep well. Today, she had difficulty waking him from his nap, so she brought him to be evaluated.

  10. Question #1 • A 12 yo female presents to the ED with a 1 ½ day h/o severe, throbbing right-sided frontemporal head pain. It necessitated her staying home from school today. She has had similar HAs in the past. She also c/o associated nausea, vomiting and sensitivity to light. Sleeping helps but has not gotten rid of this HA.

  11. *Migraine

  12. Evaluation • No support for routine laboratory studies or LP • Routine EEG not recommended • Role of neuroimaging • NOT indicated in children with recurrent HAs and a normal neuro exam • Should be considered: • Recent onset of severe HA • Change in type of HA • Neurologic dysfunction • Should be done with an abnormal neurologic exam or with coexistence of seizures

  13. Management • First step: appreciate the degree of disability • Treatment regimen must balance biobehavioral strategies with pharmocologic measures

  14. Acute treatments are the mainstay of migraine management! Take the medication as soon as possible Take the appropriate dose Have the medication available at the location where the patient usually has the HAs Avoid analgesic overuse (>3-5 doses/ week)

  15. **Use should be limited to patients whose HAs occur with sufficient frequency (@ least 3/mo) or severity to warrant daily treatment**

  16. Question #2 • An 11 yo male presents to the ED with recent onset of an extreme, nonthrobbing, deep pain in and around his right eye. He has also started to notice that the pain is spreading to the right side of his face. There has been no h/o trauma to that eye or side of the face. Mom says that his face appears more flushed than usual, and his right eye appears swollen and watery.

  17. Cluster Headache • Rare in children <10yo • 90% of sufferers are male • Extreme nonthrobbing deep pain in and around one eye that spreads onto the face on the affected side • Bursts of pain last 60-90 mins and repeat 2-6 times per day for several weeks, then vanish for a period of months to years • Accompanying facial flushing and eye swelling/ watering

  18. Cluster Headache • Treatments • Acute attacks • Sumatriptans • 100% O2 @8-10 lpm • Prophylaxis • Methysergide • Lithium • Corticosteroids

  19. Question #3 • A 9 yo female presents to her PCP with a month h/o recurrent HAs. She says it feels like there is a “tight rubber band” around her head. Mom has received a phone call from the school almost daily around 2pm regarding these HAs. Ibuprofen and rest seem to relieve the HAs. Mom is concerned that she has missed so many afternoons of school, which may affect her ability to get into Harvard.

  20. *Stress or Tension Headache • Diffuse, symmetrically distributed, throbbing pain around the head (“band like”) • Usually present most of the time, but there may be symptom-free periods • Fatigue is a common feature • Nearly all children who have daily HAs where an organic cause has been eliminated, underlying social or emotional difficulties can be found

  21. *Stress or Tension Headache • Treatment • Acute • Identify the predisposing, precipitating and perpetuating factors in the child’s home or school…and avoid them (if possible)! • Rest • Analgesia • Chronic • Relaxation techniques • Massage therapy • Acupuncture • Amitryptiline

  22. Question #4 • A 13 yo female with h/o migraines presents to the PCP with c/o increasing HA frequency. She reports that the location and severity have not changed. Instead of getting headaches once every 2 weeks, however, she is currently getting them daily. She was initially taking 200mg of Ibuprofen every 4-6h for her HAs, but that did not provide her with sufficient relief. She then switched to Excedrin Migraine and currently takes 2 pills about every 8 hours.

  23. *Medication Overuse Headache • Can occur with opiates, ergotamines, NSAIDs, or acetaminophen • Treatment includes tapering off acute symptomatic treatment (and educating the patient!) • Limit PRNs to one dose/day and 3 doses per week • Consider prophylactic treatment • Emphasize the importance of diet, exercise and sleep

  24. Question #5 • A 5 yo male presents to the ED with a three week h/o HA. It started after a minor fall on the playground and has gotten worse despite attempts to treat with both Tylenol and Ibuprofen. Mom also comments on his “unluckiness,” as he recently acquired a GI illness which has caused him to vomit frequently and not sleep well. Today, she had difficulty waking him from his nap, so she brought him to be evaluated.

  25. Headache Due to Increased ICP • Time to worry!!!

  26. Causes • Meningitis/ encephalitis • Diabetic ketoacidosis • Mass lesion • Tumor • Hemorrhage • Hydrocephalus • Tumor • Congenital malformation • Hypoxic-Ischemic encephalopathy • Pseudotumorcerebri

  27. Concerning Historical Features • Chronic and PROGRESSIVE HA without pain-free intervals • HA worse at night or immediately after waking • HA worse during maneuvers that increase venous pressure • Bending over • Coughing • Sneezing • Straining to stool

  28. Concerning Historical Features • Repetitive vomiting (especially early AM) • Focal neurologic signs or symptoms • Visual disturbances • Paraesthesias • Weakness • Ataxia

  29. Signs and Symptoms Infants Toddler/ School-age Children Lethargy or irritability HA Vomiting Papilledema Diplopia/ enlarged blind spot Abducens palsy Mild ataxia • Widened sutures • Bulging fontanelle • Persistent downward eye deviation (“sunsetting”) • Increased head circumference

  30. Cushing’s Triad Alterations in respirations or apnea HTN Bradycardia

  31. *Management • ABCs!!! • BRIEF neurologic exam with assignment of GCS • HOB at 30 degrees • If life-threatening increased ICP with impending or overt signs of herniation • Mannitol • Moderate hyperventilation

  32. *Management • Imaging/ diagnostic studies • CT • Allows rapid definition of surgical lesions • Sensitive to bony abnormalities • MRI • Exquisite resolution of brain anatomy and delineation of CBF • Sensitive to cerebral edema and demyelinating d/o • Superior to CT for visualization of the posterior fossa, cortical contusions, and white matter shearing lesions

  33. *Management • Imaging/ diagnostic studies • LP • Diagnostic for meningitis, encephalitis, pseudotumorcerebri • Contraindicated • Signs of increased ICP/ focal deficit • Coagulopathy • Hemodynamic instability

  34. *Management • Isotonic IVF • Vasopressors • CPP=MAP-ICP • CPP>60mmHg (>50 mmHg in infants and young kids) • ICP<15-25mmHg • Monitor serum electrolytes • DI • Cerebral salt wasting • SIADH

  35. *Management • Control agitation, fever, seizure activity • Maintain oxygenation, ventilation and hemodynamic stability to prevent secondary brain injury • Steroids • Only with cerebral edema associated with intracranial malignancy

  36. Thanks for your attention!! Noon Conference: Guest speaker, Dr. Peters on VUR

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