Headache resident survival guide (pediatrics)

Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Neepa Shah, M.B.B.S.[2]; Hanan E. Elkalawy, MD[3]

Synonyms and keywords: Headache in kids, Pedicatic headache, approach to headache in children

Headache resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

pain in the face, head, or neck is manifested by Headache. It can occur as a migraine, tension-type headache, or cluster headache. Headaches can occur as a result of many conditions. There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society. Treatment of a headache depends on the underlying cause, but commonly involves pain medication. A headache is one of the most commonly experienced of all physical discomforts.

Classification

According to the ICHD- 3 (The International Classification of Headache Disorders 3rd edition) headache in children can be classified into 2 types based on the origin of the headache into Primary and Secondary headache

Primary headache is due a primary brain pathology they are mostly benign in nature.

• Migrane
• Tension Headache
• Cluster Headache

Secondary headache is due to any other underlying conditions:

• Meningitis
• Brain abcess
• Subdural Hematoma
• Encepahlitis
• Sinusitis
• Idiopathic intracranial hypertension
• Hydrocephalus

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Brain tumor
• Subdural Hematoma
• Meningitis
• Encephalitis
• Ventriculoperitoneal shunt
• Brain abscess
• Cerebral aneurysm
• Increased intracranial pressure

Common Causes

• Rhinitis
• Head trauma
• Migraine
• Tension Headache.
• Trigeminal autonomic Cephalalgia (Cluster Headache).

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. The initial rapid evaluation is based on the guidelines:

Signs and symptom of a child with brain tumor. These children will need urgent CNS imaging and referral to a Child Neurologist.

• Headache Characteristics:
  • New persistant headache especially if for more than 4 weeks.
  • Change in nature of headache in previously diagnosed headache in children.
  • Symptoms like holding the head in children of age less than 4 years .
• Persistent nausea and vomiting on waking up especially if going on for more than 2 weeks.
• Eye examination
  • Papilloedema
  • Optic atrophy
  • New onset nystagmus
  • Proptosis
  • Visual field reduction
  • New onset paralytic non-comitant squint
  • Abnormal fundoscopy
• CNS Examination
• Nuchal rigidity
  • Motor signs
    • A regression in motor skills
    • Focal motor weakness
    • Abnormal gait and/or coordination (unless local cause)
    • Bell’s palsy (isolated lower motor facial palsy) with no improvement within 4 weeks
    • Dysphagia (unless local cause)
    • In infants - Change in hand or foot preference
    • Loss of learnt skills
  • Lethargy
  • Seizure
  • Atypical aura- basilar type, hemiplegic.
  • Cluster headache in Child
  • Brief cough headache in a child

Complete Diagnostic Approach

Primary Headache

type	Migraine	Tension Headache	Cluster Headache
clinical features	❑ Onset- Starts in first decade of life, gradual in onset, crescendo pattern. ❑ Intensity- Moderate to severe. ❑ Presentation- Bilateral in young children, unilateral in adolescents. ❑ Frequency- 2-4 times/month. ❑ Duration- 2-3 hours in young children, 48-72 hours in the adolescent. ❑ Character- Throbbing pulsating. ❑ Aggravating factors- bright light, noise, strong food odor. ❑ Alleviating factors- Darkroom, cool compress, sleep. ❑ Family history is a strong indicator. Migraine without aura criteria: At least 5 attacks fulfilling A to C: A. 4-72 hour duration of the headache. B. 2 of the following 4 - Unilateral location Pulsating character of pain Moderate to severe intensity. Aggravated by physical activity C. Headache associated with nausea, vomiting, photophobia, and phonophobia. Migraine with typical Aura. At least 2 attacks fulfilling criteria A to B: A. Aura can be visual, sensory, speech each fully reversible but no motor, brain stem, or retinal symptoms. B. At least 2 of the 4: Aura symptom spreads gradually over 5 or more minutes. Duration- Aura symptoms last 5-60 minutes. At least one aura symptom is unilateral. Aura is followed within 60 minutes by headache. Migraine with Brain stem Aura: At least 2 attacks fulfilling criteria A to C. A. Aura consisting of visual, sensory, and or speech each fully reversible but no motor or retinal symptoms. B. At least 2 of the following brain stem symptoms Dysarthria, vertigo, tinnitus, diplopia, ataxia, decreased level of consciousness. C. At least 2 of the following 4 At least 1 aura symptom spreads over 5 minutes and 2 or more occur in succession. Each individual aura lasts 5-60 minutes. At least 1 aura is unilateral. Aura is accompanied or followed within 60 minutes by headache. Vesticular Migrane with vertigo: At least 5 episodes fulfilling criteria A, B, and C. A. Current or past history of migraine with aura or migraine without aura. B. Vestibular symptoms of moderate to severe intensity lasting 5 minutes to 72 hour C. At least 50% of episodes are associated with at least 1 of the following Headache with at least 2 of the following 4 characteristics. Unilateral location, pulsating quality, moderate to severe intensity, and aggravation by routine physical activity. Photophobia and phonophobia. Visual aura	❑ Duration - minutes to days, the variable can be all day (30 mins - 7 days). ❑ Alleviating factors- Tension headache decreases with sleep. Pain does not worsen with routine physical activity. Not associated with photophobia or phonophobia. ❑ Presentation- Episodic non-throbbing headache, constant pressure, bilateral pressing tightening in quality, mild to moderate intensity. Bilateral pressure tightness that waxes and wanes. ❑ Severity- Mild to moderate severity. ❑ Location - diffuse. ❑  Diagnostic Criteria At least 10 episodes of headache fulfilling criteria A through C. Infrequent and frequent episodic sub forms of TTH are distinguished as follows: Infrequent episodes - Headache occurring < 1 day /month on average <12 days per year. Frequent episode - Headache occurring on 1-14 days/ month on average for >3 months (>12 and <180 days/year). A. Headache lasting 30 min - 7 days B. 2 of the following 4 Bilateral location, pressing/tightening (non - pulsating) quality. Mild or moderate intensity. Not aggravated by routine physical activity such as walking or climbing stairs. C. No nausea or vomiting, no more than one of photophobia or phonophobia.	❑ Duration - minutes to days, the variable can be all day (30 mins - 7 days). ❑ Alleviating factors- Tension headache decreases with sleep. Pain does not worsen with routine physical activity. Not associated with photophobia or phonophobia. ❑ Presentation- Episodic non-throbbing headache, constant pressure, bilateral pressing tightening in quality, mild to moderate intensity. Bilateral pressure tightness that waxes and wanes. ❑ Severity- Mild to moderate severity. ❑ Location - diffuse. ❑  Diagnostic Criteria At least 10 episodes of headache fulfilling criteria A through C. Infrequent and frequent episodic sub forms of TTH are distinguished as follows: Infrequent episodes - Headache occurring < 1 day /month on average <12 days per year. Frequent episode - Headache occurring on 1-14 days/ month on average for >3 months (>12 and <180 days/year). A. Headache lasting 30 min - 7 days B. 2 of the following 4 Bilateral location, pressing/tightening (non - pulsating) quality. Mild or moderate intensity. Not aggravated by routine physical activity such as walking or climbing stairs. C. No nausea or vomiting, no more than one of photophobia or phonophobia. ||

Secondary headache

type	Neoplasm	Sinusitis	Bacterial Meningitis	CO Poisoning	Intracranial Hemorrhage	Cerebral Abscess
clinical features	❑  Location- Occipital. ❑  Position- Recumbent, straining, Valsalva. ❑  Neurologic deficit- Ataxia, altered mental status, binocular horizontal diplopia. ❑  Presentation- Change in quality, severity, frequency, and pattern of headache. Nausea and vomiting between headache. Headache worst on first awakening in the morning. ❑  Neurologic exam - Complicated migraine, seizure or very brief aura, < 5-minute atypical aura. ❑  Recent change in weight or vision- Pituitary tumor, Craniopharyngioma, idiopathic intracranial hypertension. Diagnostic criteria — Proposed diagnostic criteria for headache attributed to intracranial neoplasm have been developed by the International Headache Society PMID: 29368949 For headache attributed directly to neoplasm, the diagnostic criteria are as follows: Any headache fulfilling criterion 3 (below) A space-occupying intracranial neoplasm has been demonstrated Evidence of causation demonstrated by at least two of the following: Headache has developed in temporal relation to the intracranial neoplasia or led to its discovery Either or both of the following: -Headache has significantly worsened in parallel with worsening of the neoplasm -Headache has significantly improved in temporal relation to successful treatment of the neoplasm Headache has at least one of the following four characteristics: -Progressive -Worse in the morning and/or when lying down -Aggravated by Valsalva-like maneuvers -Accompanied by nausea and/or vomiting Not better accounted for by another International Classification of Headache Disorders, third edition (ICHD-3) diagnosis Formal diagnostic criteria also exist in the ICHD-3 for headaches attributed to more specific tumors , including a colloid cyst of the third ventricle, carcinomatous meningitis, and pituitary adenoma.	❑ Duration - categorize into Acute bacterial sinusitis (ABS)(nasal and sinus symptoms for at least 10 days and fewer than 30 days).- Subacute sinusitis is (nasal and sinus symptoms lasting longer than 4 weeks and fewer than 12 weeks).- Chronic sinusitis is (symptoms of at least 12 weeks’ duration) . ❑ Location - There are four different types of sinuses:-Ethmoid sinus - Maxillary sinus -Frontal sinus.-Sphenoid sinus. ❑ Aggravating factors- Headache worsens in the morning after sleeping due to accumulation of secretion and also it increase with inflammation of nasal mucosa. ❑ Frequency- Tension-type headache can last from 30 minutes to several days.- It is uncommon in children under 10 years of age. They usually: Occur in groups of five or more episodes, ranging from one headache every other day to eight a day that lasts less than three hours.-chronic daily headache" (CDH) for migraines and tension-type headache that occur more than 15 days a month. ❑ Character- Tension-type headaches cause: pressing tightness in the muscles of the head or neck, Mild to moderate, non pulsating pain on both sides of the head Pain that's not worsened by physical activity, Headache that's not accompanied by nausea or vomiting, Younger children may withdraw from regular play and want to sleep more. Cluster headaches involve sharp, stabbing pain on one side of the head and accompanied by tear, congestion, runny nose, or restlessness or agitation. ❑ Associated factors- Tension-type headaches cause Pain that's not worsened by physical activity, Headache that's not accompanied by nausea or vomiting. Cluster headaches accompanied by tear, congestion, runny nose, or restlessness or agitation. CDH may be caused by an infection, minor head injury or taking pain medications Diagnostic criteria: A-Any headache fulfilling criterion C B-Clinical, nasal endoscopic and/or imaging evidence of acute rhinosinusitis C-Evidence of causation demonstrated by at least two of the following:1)headache has developed in temporal relation to the onset of rhinosinusitis 2)either or both of the following: a) headache has significantly worsened in parallel with worsening of the rhinosinusitis. b) headache has significantly improved or resolved in parallel with improvement in or resolution of the rhinosinusitis 3)headache is exacerbated by pressure applied over the paranasal sinuses 4)in the case of a unilateral rhinosinusitis, headache is localized and ipsilateral to it D)Not better accounted for by another ICHD-3 diagnosis.	In children age 1 or older, ❑ symptoms : may include: Neck pain, Back pain, Headache, Sleepiness, Confusion, Irritability, Fever, Refusing to eat, Reduced level of consciousness, Seizures, photophobia, Nausea and vomiting, Neck stiffness, A purple-red splotchy rash ❑  Tests needed to be done, such as: A]Lumbar puncture (spinal tap). This is the only test that diagnoses meningitis. A needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain is measured. A small amount of cerebral spinal fluid (CSF) is removed and sent for testing to see if there is an infection or other problems. B]Blood tests. These can help diagnose infections that cause meningitis. C]CT scan or MRI. These are tests that show images of the brain. A CT scan is sometimes done to look for other conditions that may cause similar symptoms as meningitis. An MRI may show inflammatory changes in the meninges. These tests give more information. But meningitis can’t be diagnosed using these tests alone. D]nasal, throat, or rectal swabs. These tests help diagnose viral infections that cause meningitis.	❑ Effects of carbon monoxide in relation to the concentration in parts per million in the air : -35 ppm (0.0035%), (0.035‰);Headache and dizziness within six to eight hours of constant exposure.- 100 ppm (0.01%), (0.1‰);Slight headache in two to three hours.- 200 ppm (0.02%), (0.2‰);Slight headache within two to three hours; loss of judgment.- 400 ppm (0.04%), (0.4‰);Frontal headache within one to two hours.- 800 ppm (0.08%), (0.8‰);Dizziness, nausea, and convulsions within 45 min; insensible within 2 hours. -1,600 ppm (0.16%), (1.6‰);Headache, increased heart rate, dizziness, and nausea within 20 min; death in less than 2 hours.-3,200 ppm (0.32%), (3.2‰);Headache, dizziness and nausea in five to ten minutes. Death within 30 minutes.-6,400 ppm (0.64%), (6.4‰);Headache and dizziness in one to two minutes. Convulsions, respiratory arrest, and death in less than 20 minutes.-12,800 ppm (1.28%), (12.8‰);Unconsciousness after 2–3 breaths. Death in less than three minutes. ,	❑ Symptoms : Sudden, severe headache, Dizziness or fainting, Trouble with vision, speech, or movement, Confusion, extreme irritability, or sudden personality change, or coma, Fever, Stiff neck, Seizures or convulsions, Nausea and vomiting. ❑ Tests needed to be done. These can include : A-MRI or CT scan. These give detailed pictures of the brain. They are used to help check for bleeding. During the test, fluid called contrast dye may be used to make the blood vessels and brain easier to see. B-Angiography. This test takes pictures of the blood vessels in the brain. During the test, a thin tube called a catheter is guided into the blood vessels leading to the brain. Contrast dye is sent through the tube. This is to make the blood vessels easier to see. This test can also be done with an MRI or CT scan. C-Transcranial doppler (TCD). This test shows the flow of blood through the blood vessels in the brain. It uses harmless sound waves to form pictures of the brain and blood vessels. It's used to monitor ongoing conditions that may worsen the bleeding. D-Blood tests are done to find risk factors. The tests include platelet count and other tests to measure blood clotting.	brain abscess have a dull, achy headache. this is the only symptom. The pain usually is limited to the side of the brain where the abscess is, and the pain usually becomes worse until the abscess is treated. Aspirin and other pain medication do not relieve the pain. brain abscess have a low-grade fever. Other symptoms may include nausea and vomiting, neck stiffness, seizures, personality changes and muscular weakness on one side of the body.

Treatment

Shown below is an algorithm summarizing the treatment of [[ migraine & tension headache]] according the the [ the international classification of headache disorders] guidelines.

Treatment

discrimination training

Biofeedback constitutes

Cognitive therapy or cognitive stress coping training

1. Discrimination training focusing on identification of tense and relaxed larger muscle groups; differential relaxation (some muscle groups are tensed while other muscles are relaxed); cued relaxation (pairing breathing to a relaxing word, such as calm, peace, or relax); minirelaxation focused on a limited number of muscles in the head, neck, or shoulder and applied regularly throughout the day(whenever the watch is looked at, the school bell rings, etc.); and application of techniques in everyday life (when headaches and feelings of stress tend to occur). Relaxation treatment is typically delivered over 8 to 10 sessions, administered either individually or in groups.

2. Biofeedback constitutes another common approach for pediatric headache (and this approach is well studied for adults as well). Historically, thermal biofeedback has been used most often for migraine headache and electromyogram (EMG) biofeedback for tension-type headache When used with patients with headache, these procedures likely work in a similar manner, by promoting generalized relaxation, and thus they may be interchangeable. Work is only now beginning to evaluate specific types of biofeedback that directly target physiology presumed to underlie headaches. This includes electroencephalogram (EEG) biofeedback and blood volume pulse biofeedback.

3. cognitive therapy or cognitive stress coping training has been much less investigated; however, it too has promise. Cognitive approaches have been combined with other major treatment modalities, and the experimental designs employed have not made it possible to partial out the source of effects.

Do's

• Pain Behavior Management Guidelines for Parents .
  • 1. Encourage independent management of pain: Praise and publicly acknowledge practice of self-regulation skills during pain-free episodes. If pain is reported, issue a single prompt to practice self-regulation skills. Praise and reward normal activity when report of pain has been made.
  • 2. Encourage normal activity during pain episodes: Insist on attendance at school, maintenance of daily chores and responsibilities, participation in regular activities (lessons, practices, clubs).
  • 3. Eliminate status checks: No questions about whether there is pain or how much it hurts.
  • 4. Reduce response to pain behavior: No effort should be made to assist the child in coping. Do not offer assistance or suggestions for coping. Do not offer medications.
  • 5. Reduce pharmacological dependence: If medication is requested, deliver only as prescribed (i.e., follow directed time table).
  • 6. Recruit others to follow same guidelines: School personnel should not send child home; child should be encouraged and permitted to practice self-regulation skills in the classroom, workload should not be modified.
  • 7. Treat pain requiring a reduction in activity as illness: If school, activities, chores, or responsibilities are missed, the child should be treated as ill and sent to bed for the remainder of the day, even if pain is resolved. Do not permit watching television, playing games, or special treatment.

Don'ts

• Failure to reassess a child with migraine or tension headache when the headache character changes
• Attributing persistent nausea and vomiting to an infective cause in the absence of corroborative findings, eg, contact with similar illness, pyrexia, diarrhea
• Failure to fully assess vision in a young or uncooperative child
• Failure of communication between community optometry and primary and secondary care
• Attributing abnormal balance or gait to middle ear disease in the absence of corroborative findings
• Failure to identify swallowing difficulties as the cause of recurrent chest infections or “chestiness”
• Attributing impaired growth with vomiting to gastrointestinal disease in the absence of corroborative findings
• Failure to consider diabetes insipidus in children with polyuria and polydipsia