Headache resident survival guide (pediatrics)

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

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

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

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

Shown below is an algorithm summarizing the diagnosis of [[Headache]] according to the [...] guidelines.

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|C03=Migrane|C01=Tension Headache|C02=Cluster Headache}}

Headache

Primary Headache

Secondary Headache

Migrane

Tension Headache

Cluster Headache

Neoplasm

Sinusitis

Bacterial Meningitis

CO Poisoning

Intracranial Hemorrhage

Cerebral Abscess

{{{ Migraine 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. }}}

{{{ ❑ 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 subforms 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 - 5-15 minutes but may last 60 minutes. ❑ Location - Temporal or retro-orbital. Unilateral begins around the eye or temple. ❑ Aggravating factors- Headache worsens when lying down or resting. ❑ Frequency- Can occur every other day sometimes 8times/day. ❑ Onset- Pain begins quickly and reaches in a crescendo pattern within minutes. ❑ Duration- Can remain active for 30 minutes. ❑ Character- Deep continuous excruciating pain. ❑ Associated factors- Ipsilateral lacrimation, redness of the eye, stuffy nose, rhinorrhea, pallor, sweating, Horner syndrome, increased sensitivity to alcohol. Diagnostic criteria: At least 5 attacks fulfilling criteria from A to C : A. Severe or very severe unilateral orbital, supraorbital/temporal pain lasting 15-180 minutes. B. Either or both : One of the following: Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, forehead, and facial sweating, miosis/ptosis. Sense of restlessness or agitation. Cluster headache can be of 2 types : ❑ Episodic cluster headache Attacks fulfilling criteria for cluster headache occurring in bouts At least 2 cluster periods lasting from 7 days to 1 year(when untreated) and separated by pain free remission periods of 3 months. ❑ Chronic cluster headache Attacks fulfill criteria for cluster headache. Attacks occurring without a remission period or with remission lasting less than 3 months for at least 1 year. }}}

{{{ ❑  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. Located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow.- Maxillary sinus. Located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow.-Frontal sinus. Located inside the face, in the area of the forehead. This sinus does not develop until around 7 years of age.-Sphenoid sinus. Located deep in the face, behind the nose. This sinus does not develop until adolescence. . ❑ 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 headaches can last from 30 minutes to several days.-Cluster headaches are 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 headaches 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. }}}

{{{ D06 }}}

{{{ D07 }}}

{{{ D08 }}}

{{{ D09 }}}

{{{ 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 }}}

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

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