Headache resident survival guide (pediatrics)
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Synonyms and keywords: Headache in kids, Pedicatic headache, approach to headache in children
Headache resident survival guide (pediatrics) Microchapters |
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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.
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
- 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
- Motor signs
Complete Diagnostic Approach
Shown below is an algorithm summarizing the diagnosis of [[Headache]] according to the [...] guidelines.
}}|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.
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 :
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:
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
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 -
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:
| {{{ 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
C. At least 2 of the following 4
| {{{ 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
Unilateral location, pulsating quality, moderate to severe intensity, and aggravation by routine physical activity.
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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