headache in childhood

8/13/2019 Headache in Childhood

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Catrinel Iliescu

Pediatric Neurology ClinicAl Obregia Clinical Hospital

Bucharest


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WHY A DISCUSSION ABOUTHEADACHE?

Headache is a frequent reason for consultation evenin childhood

When repeated, it can affect the QoL of children depending also on etiology


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WHAT IS CAUSING HEADACHE?

Intracranial pain-sensitive structuresCerebral and dural arteriesIntracranial venous sinuses and their large tributariesCranial nerves (II, III, V, IX, X)Parts of the dura at the base of the brain

Extracranial pain-sensitive structures

Extracranial arteriesCervical rootsDelicate structures of the eye, ear, nasal cavities, sinusesSkin, subcutaneous tissue, muscles, periosteum of the skull


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WHAT IS THE MECHANISM?Vasodilatation

Inflamation

Traction

Sustained muscular contraction

Supratentorial structures referred pain to anterior two-thirdsof the head (CN V)

Infratentorial structures referred pain to the neck and occiput(upper cervical roots)


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WHAT STRUCTURES ARE INSENSITIVE

TO PAIN?Brain parenchyma

Ependyma and choroid plexuses

Much of the pia-arachnoid and dura over theconvexity of the brain

Bony skull


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CLASSIFICATION

Etiological criteria

Temporal criteria


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ETIOLOGICAL CRITERIA

PRIMARY HEADACHE

Migraine

Paroxysmal unilateral headaches

Cluster headache

Tension-type headache

SECONDARY HEADACHE

Infections of the CNS

Intracranial haemorrhages

Increased intracranial pressure,

varied etiologies


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TEMPORAL CRITERIA

ACUTE HEADACHE

ACUTE RECURRENT HEADACHE

CHRONIC NON PROGRESSIVE HEADACHE

CHRONIC PROGRESSIVE HEADACHE

MIXED


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MANAGEMENT OF THE CHILD WITHHEADACHE

HISTORY

CLINICAL EXAMINATION

COMPLEMENTARY EVALUATIONS

DIAGNOSIS

TREATMENT


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MANAGEMENT OF THE CHILD WITHHEADACHE THE HISTORY

The key of a correct diagnosis

Questions for the child + parents

Onset (abrupt, slowly progressive..)LocationTypeIntensityDuration

FrequencyRelieving factorsPrecipitating/ aggravating factorsAssociated signs (autonomic, neurological, others)FAMILY HISTORY


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MANAGEMENT OF THE CHILD WITHHEADACHE THE CLINICAL EXAMINATION

Very important also

General state, febrile / not / meningeal signs!

BP

Palpation of facial sinuses

NeurologicalConsciousnessCranial nerves papilloedemaGait, fine movements / Coordination

Reflexes (DTR, pathological reflexes)

Sensory testing


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MANAGEMENT OF THE CHILD WITHHEADACHE COMPLEMENTARY EVALUATION

Always related to the history and clinical examination!

Imaging

EEG

LP

Routine biological screening

Other referrals ophtalmology, ENT, psychiatrist


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RED FLAGSThunder-clap headache (severe headache of sudden onset)

Headachewith abnormal neurological examinationwith fever and meningeal signs!without fever, with meningeal signswith seizures

Short history of headache

Persistently lateralized headacheProgressive course of headache

Occipital headache in a child


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ACUTE HEADACHE = recent onset ofheadache, no previous history of headaches

ETIOLOGICAL POSSIBILITIES

Febrile illness

Infections of CNS

Cranial trauma

Intracranial haemorrhage

Post-punctional headache

Exertional headache

After a first seizure

First attack of migraine

Localized


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ACUTE RECURRENT HEADACHE = repeatedattacks of headache, no signs/symptoms

between attacksMigraine the most frequent cause of recurrent headache

Hereditary condition

Recurrent headache

Usually unilateral and throbbing

Associated with autonomic signsSometimes with neurological signs

Typically relieved by sleep in childhood


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CLASSIFICATION OF MIGRAINE

Migraine without aura (common migraine)

Migraine with aura

Migraine variants


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EPIDEMIOLOGY OF MIGRAINE

Migraine is among the most prevalent neurological

conditions

Approx 7% of children 5-15 y do have migraine

Approx 15% of all people will have migraine

Most adults will have their first migraine < 20 y of age

(20% before age of 5y!)

Family history is + in approx 60-80% of cases


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MIGRAINE PATHOGENESIS

Mechanisms proposed:

Neurovascular

Vascular

Neuronal

Neurotransmitter

Channelopathy

Mithocondrial disfunction


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MIGRAINE WITHOUT AURA(60-85% of cases)

5 or more attacks of headaches

Duration 1-48 h

Headache has at least 2 of the following characteristics:

Bilateral (frontal or temporal) or unilateral location

Pulsatile quality

Moderate to severe intensity

Aggravated by routine physical activity

During the headache, 1 of the following occurs:

Nausea or vomiting

Hyperestesia (photophobia and phonophobia)


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MIGRAINE WITH AURA (15% of cases)

At least 2 attacks fulfilling the following criteria:

At least 3 of the following characteristics:One or more fully reversible aura symptom indicating focal cortical

and/or brainstem dysfunction

At least one aura developing gradually > 4 min or >=2 aura symptoms

developing in succession

No auras > 60 min

Headache following no more than 60 minutes after the aura

Headache will have the characteristics described before


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CHRONIC UNPROGRESSIVE HEADACHE =tension-type headache

Persistent headache with no associated autonomic

symptoms, no neurological signs

Mild, diffuse, does not interact with routine activities

Most often related to psychological factors (tension)

Except psychological evaluation no other complementary

evaluation is needed

(some exceptions do exist)


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CHRONIC PROGRESSIVE HEADACHERED FLAG! usually symptomatic

Initially episodic headache but short after

becomes persistent and progressive

Can awake a child from sleep (toward morning) / is evident

immediately after awakening

Often vomiting is associated, can relieve headache

Aggravated by straining, coughing, sneezingMechanism: traction, infiltration

Clinical examination: usually (?) abnormal if rigurous

(including search for papilloedema); tilted head; OFC


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MIXED HEADACHE

Most often a pattern of episodic headache transformed

into a chronic unprogressive one

Psychological factors contribute

Analgezics overuse

Transformed migraine (chronic migraine)


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TREATMENT

Symptomatic analgetics

Etiopathogenic:

Antibiotics if bacterial meningitis, cerebral abcessAntivirals if viral (herpetic) encephalitis

Surgery if acute epidural/ subdural haematoma folowing BT

Liquids, salt, caffeine if postpunctionalSurgery if intracranial mass / hydrocephaly

Antimigraine treatments

Antidepressants if needed in tension type headache


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MIGRAINE MANAGEMENT

Acute treatment:

Analgetics

Antiemetics

Triptans

Ergot derivates

Chronic prophylaxy frequent attacks, complicated

Propranolol

Valproic acid, topiramate long-term treatments (mth)

amytriptiline


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MIGRAINE MANAGEMENT

Behavioral management:

Avoidance of analgetic over-use

Regular sleep (not too long, too short)

Regular meals, breakfast important for children

During a headache

Avoidance of stimuli

Encouraging sleep the most powerful treatment for childhood

migraine


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headache in childhood

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