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. }}}

{{{ D05 }}}

{{{ 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

References

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