�ݺ�ߣ

APPROACH TOA CHILD
WITH HEADACHE…
ATIQA IMTIAZ
R II
PAEDS III

 Headache is 3rd
leading cause of hospital visits..
 And is most common complaint in children and
adolescent….
 Headache can be a primary problem or secondary
to an underlying illness….
 Primary headaches are most often recurrent,
episodic headaches and in all instances
neurological examination is normal…
 The presence of abnormal neurological
examination or unusual neurological symptoms is
a key clue that additional investigation is
warranted….

MAIN CATEGORIES OF HEADACHE:
PRIMARY:
Migraine
Tension type
Trigeminal Autonomic Cephalalgias(TACS)
Cluster headache
Other primary headaches
new daily persistent headache

SECONDARY HEADACHE:
 Tumor/Mass
 Vascular lesions
 Increased ICP due to other causes…

APPROACH TO A CHILD WITH HEADACHE pediatrics.pptx

GENERAL APPROACH TO
HEADACHE:
HISTORY

PHYSICAL EXAMINATION:
•Vital signs,including blood pressure
• temperature…
•Palpation of head and neck to asses
for sinus tenderness, muscle tightness
or nuchal rigidity…
•Head circumference (even in older children)
•Skin assessment for neurocutaneous syndrome…
•Detailed neurological examination with
particular attention to fundoscopic examiation,
eye movements, head tilt, finger-nose-finger
testing for dysmetria, and tandem(heal-toe)
gait for ataxia….

CLASSIFICATION AND DIAGNOSTIC CRITERIA
OF HEADACHE ACCORDING TO ICHD-BETA 3:
Migraine:
 Migraine is the most frequent of recurrent headache that is
brought to the attention of parents and care providers.
 Migraine is characterized by episodic attacks that may be
moderate to severe in intensity, focal in location on head,
have a throbbing quality, and associated with nausea,
vomiting,n light sensitivity, and/or sound sensitivity.
 Compare to adults, paediatric migraine is bilateral, often
bifrontal, location…

TENSION TYPE HEADACHE:
The ICHD-beta 3 sub classify tension type headache further
In to INFREQUENT(<12 times /year), frequent(1-15
times/month), and chronic(>15 headaches/month)…
Tension type headache can further be separated into headaches with or
without pericarnial tenderness…

SECONDARY HEADACHES:
 ICHD-beta 3 classify secondary headaches listed
in table below….
 Secondary headaches are also known as RED
FLAGS….

•HEADACHE ATTRIBUTEDTO TRAUMA OR INJURY TO THE
HEAD AND/OR NECK.
•HEADACHE ATTRIBUTED TO CRANIAL VASCULA DISORDER.
•HEADACHE ATTRIBUTED TO NON-VASCULAR INTRACARNIAL
DISORDER
•HEADACHE ATTRIBUTTED TO SUBSTANCE WITHDRAWAL.
•HEADACHE ATTRIBUTED TO INFECTION.
•HEADACHE ATTRIBUTEDTO DISORDER OF HEMOSTASIS.
•MEDICATION-OVERUSE HEADACHE.

HEADACHE MANAGEMENT:
 1) Acute (for intractable headache)
 2) Preventive
 3) Biobehavioral( headache hygiene)

ACUTE MANAGEMENT: MANAGEMENT OF
ACUTE ATTACK IS TO PROVIDE HEADACHE FREEDOM AS
QUICKLY AS POSSIBLE WITH RETURN TO NORMAL
FUNCTION.
 Three drugs to be consider:
 NSAIDS( ibuprofen 7.5-10mg/kg), however,
Acetaminophen(15mg) can be effective in those with
contraindication to NSAIDS…
 In addition ,overuse needs to be avoided, limiting the NSAIDS to
not more than 2-3 times per week.
 When headache is especially severe not relieved on NSAIDS add
TRIPTANS:
 FDA approved are 3:
 Almotriptan (12-17yrs)
 Rizatriptan (young as 6 years)
 Zolmitriptan (12years)
 Antiemetics (prochlorperazine and metocloparamide).

 For intractable headaches: when attack does not respond to acute out
pateint regimen and headache is disabling, more aggressive
therapeutics approaches to prevent further increase in the duration as
well as the frequency of headache:
 Antidopaminergic drugs: prochlorperazine(0.15mg/kg) and
metoclopramide(0.13-0.15mg/kg). These medications are usually well-
tolerated but, extrapyramidal reactions are more frequent in children
which can be controlled by Diphenhydramine(20-50mg).
 NSAIDS: Ketorolac
 Triptans: subcutaneous sumatriptan(0.06mg)…but contraindicated in
hemiplegic migraine.
 DHE: before giving this medication pateint should pre medicated with
0.13-0.15 mg/kg of prochlorperazine 30min prior. Maximum of three
doses to prevent extrapyramidal symptoms.
 Dose 0.5-1.0mg every 8 hours, first dose should be divided into2 half
doses separated by 3omin…
 Antiepileptics: Sodium Valporate (15 to 20mg /kg push over 1omin
followed by oral dose 15-20mg/day).

PREVENTIVE THERAPY:
 When the headaches are frequent (more than one headache
per week) or disabling(causing the patient to miss school,
home, or social activities, or having PedMIDAS score>2),
preventative or prophylactic therapy may be warranted.
 Goal is to reduce the frequency( to 1 to 2 headaches or fewer
per month) and level of disability score<10.
 Prophylactic agent should be given for at least 4 to 6months
and then weaned over several weeks…
 Most commonly used are:
 1) Amitriptyline
 2)Topiramate
 3)Cyproheptadine
 4)Valporic acid

BIOBEHAVIORAL:
DIETARY TRIGGERS:
ALCOHOL,CAFFEINE,
CHOCOLATES,
NUTS,BANANAS,
STRAWBERRIES….

LITTLE BIT ABOUT BRAIN TUMOR
HEADACHE:
 Headache associated with brain tumors are often of new onset,
persistent, associated with neurological findings (papillodema,
cognitive behavioral changes, seizures, focal motor deficits),
emesis, HEADACHE severe enough to wake the patient from sleep
or occur on awakening.
 Gait changes
 Head tilt
 Diplopia

SOME CASE SCENARIO WHICH WE DEAL IN E/R AND
OPDS…
 QNO:1) A 5 Year old girl with a history of central cyanosis
since birth now admitted with low grade fever, headache and
lethargy for 3 days and loss of consciousness for two hours, her CT
scan was done. Shown below:

 a) Describe the ct scan brain.
 b) what is likely diagnosis?
 c) Enlist the other causes of this condition.
 d) how will you manage this child?

ANSWER:
 A) CT scan brain with contrast showing multiple ring
enhancing lesions of variable sizes in frontal and occipital
lobe.
 B) cerebral abscess due to cyanotic heart disease due to
embolization through right to left shunts.
 C) meningitis, mastoiditis, sinusitis, infections of the VP
shunts.

QNO#2:
 A 13 year old girl present with a complain of 3 month
history of recurrent headaches. These occur on a daily basis
and are worse when lying flat or banding down. Her BMI is
28.8kg/m2. The neurological examination is normal except
for a right 6th
nerve palsy and evidence of early bilateral
papilledema. Blood pressure is 130/75 mmHg. The MRI
brain scan is reported as normal.
 Investigations: full blood count: normal, glucose 4.5mmol/l,
UCE normal.
 CSF: appearance clear, no red cells, no white cells.
 Protein 0.4, glucose 3.4mmol/l, gram stain negative,
opening pressure 30cm h2o(23mmHg).

a) What is likely diagnosis?
b) What is the most important complication?
c) What are treatment options?

 Idiopathic interacranial hypertention.
 Loss of visual acuity.
 Acetazolamide (10-30mg/kg/24 hours).

a) What is the most likely diagnosis?
b) What are the common causes?

QNO#4
 A previously healthy 7-year-old boy was hospitalized
in january 2021 with a 2-week history of
progressively worsening symptoms of nausea,
vomiting, headache which became worse especially
in morning and tilting of head. Mother also complain
about behavioral changes that child became more
aggressive. Upon admission, his examination
significant for neck stiffness, papilledema, up going
plantar on right side and power of 4/5 and GCS of
15/15…there no history of ear drainage, tb contact
or previous hospital admission…Initially CT scan
brain plain showed normal imaging then LP were
perfomed which was normal….Urgent MRI with
contrast shown below…

a) Describe positive findings in MRI?
b) What is the likely diagnosis?
c) What are D/D?
d) Treatment options?

 A) MRI brain showing hypodense mass in
cerebellum that is extending in to 4th
ventricle…
 B) Medulloblastoma
 C) A multimodal treatment approach is pursued
in medulloblastoma, with surgery as starting
point of treatment
 It is both sensitive to chemotherapy as well as
radiotherapy….

�ݺ�ߣ

APPROACH TO A CHILD WITH HEADACHE pediatrics.pptx

More Related Content

APPROACH TO A CHILD WITH HEADACHE pediatrics.pptx