headaches practical approach dr maltby. chronic headache migraine tension headaches/chronic daily...
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HeadachesHeadachesPractical approachPractical approach
Dr MaltbyDr Maltby
Chronic Headache Chronic Headache
MigraineMigraineTension headaches/chronic daily headachesTension headaches/chronic daily headachesTeeth/Nocturnal grindingTeeth/Nocturnal grindingSinus congestionSinus congestionVisualVisualSleep apnoeaSleep apnoeaBenign Occipital EpilepsyBenign Occipital EpilepsyBIHBIHRaised intracranial pressure Raised intracranial pressure
When to scanWhen to scan
Very young childrenVery young childrenChange in the character of headachesChange in the character of headachesHistory suggestive of raised ICPHistory suggestive of raised ICPFocal neurological SignsFocal neurological SignsPapillodema – not optic detrusum Papillodema – not optic detrusum Headache with erratic vomitingHeadache with erratic vomitingFH or anxiety of IC lesionFH or anxiety of IC lesionBIH with optic nerve viewsBIH with optic nerve views
Mausley StudyMausley Study
Very old study 1998Very old study 1998Looked at children with CNS tumours Looked at children with CNS tumours mode of referral and the symptomsmode of referral and the symptomsMajority DID NOT have symptoms Majority DID NOT have symptoms classically of raised ICPclassically of raised ICPMajority DID NOT have focal neurologyMajority DID NOT have focal neurologyMajority had frequently been seen by GP Majority had frequently been seen by GP paediatricians and even a paediatric paediatricians and even a paediatric neurologist neurologist
ConclusionsConclusions
Falsely reassured by normal examinationFalsely reassured by normal examination
Signs of ICP are great but don’t helpSigns of ICP are great but don’t help
Change in character in under 5Change in character in under 5
School failure in over 5 School failure in over 5
MigraineMigraine
Episodes headaches relief with sleepEpisodes headaches relief with sleepVomitingVomitingVisual disturbance- specificVisual disturbance- specificPallorPallorFH FH Motion sicknessMotion sicknessNeurological symptoms vary Neurological symptoms vary Between times pain freeBetween times pain free
ManagementManagement
Examination normalExamination normal
Scan if under 5Scan if under 5
Advice about treating the acute attackAdvice about treating the acute attack
Isolating triggers avoidance if possibleIsolating triggers avoidance if possible
Multiple Multiple
TriggersTriggers
Dietary – dairy, citrus, tomatoes, Dietary – dairy, citrus, tomatoes, blackcurrant, fizzy drinks – J2O blackcurrant, fizzy drinks – J2O
Sleep – excessive weekend lyins or sleep Sleep – excessive weekend lyins or sleep oversovers
Excitement Excitement
Stressed out Stressed out
Busy life Busy life
Busy lives Busy lives
After school clubsAfter school clubsSibs after school clubsSibs after school clubsWeekend activityWeekend activitySleep oversSleep oversHome work – plans/supervisionHome work – plans/supervisionFriendshipsFriendshipsSport activitiesSport activitiesRushing mothersRushing mothers
Management of acute attackManagement of acute attack
Immediate analgesia- emergency protocol Immediate analgesia- emergency protocol
Write to the school for their supportWrite to the school for their support
Ibrufen, MigraleveIbrufen, Migraleve
If vomiting MigraleveIf vomiting Migraleve
Very rare to need SumitryptinVery rare to need Sumitryptin
Monitor school attendance maybe late Monitor school attendance maybe late attendance better than noneattendance better than none
Preventive managementPreventive management
Depend on the frequency school Depend on the frequency school attendanceattendance
Diet exclusionDiet exclusion
Recognise triggersRecognise triggers
PziotifenPziotifen
Others treatments- Topiramate, Others treatments- Topiramate, Epilum,Gabapentin, Amitriptyline Epilum,Gabapentin, Amitriptyline
Chronic daily headacheChronic daily headache
TeenagersTeenagers
High achieversHigh achievers
Driven from within not by school/parentsDriven from within not by school/parents
Lots of mates- squabble or miss no matesLots of mates- squabble or miss no mates
Area of stress in family homeArea of stress in family home
Not helped by analgesiaNot helped by analgesia
Never wake with headache but have it at nightNever wake with headache but have it at night
Most difficult to manageMost difficult to manage
ManagementManagementGeneral adviceGeneral advice
Fluid intakeFluid intakeRegular meals- diet restrictionsRegular meals- diet restrictionsRegular exerciseRegular exerciseRegular sleep patterns – lying in!Regular sleep patterns – lying in!TV and computer usageTV and computer usageAnalgesia usageAnalgesia usageNormalising life Normalising life After school clubs and in sibsAfter school clubs and in sibsAvoid asking” do you have a headache”Avoid asking” do you have a headache”Family attitude to illness Family attitude to illness
ExplanationExplanation
Stressy teenagers learn to relax- pilartesStressy teenagers learn to relax- pilartes
Advice about studying Advice about studying
Driven from within Driven from within
Learn to live with it Learn to live with it
Treatment strategiesTreatment strategies
Dietary exclusion – formally not by diary Dietary exclusion – formally not by diary Diary – shocking what they eatDiary – shocking what they eatExclude for 6 weeks:Exclude for 6 weeks:
Diary productsDiary products Citrus/Apples in any formCitrus/Apples in any form Tomatoes and ketchupTomatoes and ketchup Fizzy drinksFizzy drinks Blackcurrant drinksBlackcurrant drinks ChocolateChocolate Marmite Marmite Anything else you can think of especially if the love themAnything else you can think of especially if the love them
Replace one thing every 4 days if there was a responseReplace one thing every 4 days if there was a response
MedicationMedication
Diet fails or the child cheats or refusesDiet fails or the child cheats or refuses
Explanation of pain modification the pain is Explanation of pain modification the pain is there but the response is different there but the response is different
Trail of Pziotfen ONLY at night – for at Trail of Pziotfen ONLY at night – for at least 6 weeksleast 6 weeks
TopiramateTopiramate
GabapentinGabapentin
Epilum Epilum
Alternative treatementsAlternative treatements
ButterburButterbur
Migraine support groupMigraine support group
Headache clinicsHeadache clinics
CAMSCAMS
BIHBIH
DO not diagnosis this unless confirmed DO not diagnosis this unless confirmed papillodeama and optic nerve swelling on papillodeama and optic nerve swelling on MRIMRI
Reproducible reduction in visual acuityReproducible reduction in visual acuity
Formal visual fields assessment is poor Formal visual fields assessment is poor even in teenagereven in teenager
Child has a risk factor – obesity and Child has a risk factor – obesity and tetracycline usage tetracycline usage
DiagnosisDiagnosis
Raised pressure on opening at LPRaised pressure on opening at LP
Not under GA straightened legsNot under GA straightened legs
Pressure above 20Pressure above 20
Therapeutic and diagnostic procedure so Therapeutic and diagnostic procedure so reduce pressure to 20 if over 40 then reduce pressure to 20 if over 40 then halve ithalve it
Dramatic response to LP in terms of Dramatic response to LP in terms of treatment treatment
PitfallsPitfalls
Repeated LPRepeated LP
Refusal to allow it without a GARefusal to allow it without a GA
Symptoms from LP confuse the pictureSymptoms from LP confuse the picture
Side effects from the DiamoxSide effects from the Diamox
Evidence that evolves residual chronic Evidence that evolves residual chronic daily headachedaily headache
Bolt monitoringBolt monitoring
Questions?Questions?
Hard work Hard work
Fits Faints and Funny turns
NoahNoah
18 months18 monthsThree episodes when his mother says he is found on the floor Three episodes when his mother says he is found on the floor unresponsive floor and jerks lasts about 30mins but father thinks unresponsive floor and jerks lasts about 30mins but father thinks less.less.Preceded by a cryPreceded by a cryAfter he appears confused and inconsolable After he appears confused and inconsolable EEG performed by the SHO after being seen in A/E- normal EEG performed by the SHO after being seen in A/E- normal ECG normal QTc 0.42secECG normal QTc 0.42sec24hr ECG normal24hr ECG normalFH father used to do this as a child and was treated with PhenytoinFH father used to do this as a child and was treated with PhenytoinComes to discuss if they should give a trail of anticonvulsantComes to discuss if they should give a trail of anticonvulsant
EllieEllie
12 years of age 12 years of age C/O fit at school C/O fit at school Fat lasting 5 minutes witness by the first aider (whose sister used to Fat lasting 5 minutes witness by the first aider (whose sister used to have fits)have fits)Called 999 by the maths teacher was sick and confused afterwards Called 999 by the maths teacher was sick and confused afterwards In A/E now feeling better fully conscious a slight headache In A/E now feeling better fully conscious a slight headache B?S by paramedics 6.5B?S by paramedics 6.5PMH febrile convulsion resulting in an PICU admission for 24 hours PMH febrile convulsion resulting in an PICU admission for 24 hours given rectal diazepam that mother still carriesgiven rectal diazepam that mother still carriesFH Mother has epilepsy on TegretolFH Mother has epilepsy on TegretolExam normal Exam normal No focal signs to find No focal signs to find One café au lait spot One café au lait spot Referred to you asking if they could attend first fit clinic and an EEG Referred to you asking if they could attend first fit clinic and an EEG has been organised has been organised
Part two - clinicPart two - clinic
Further episode occurred during home tec Further episode occurred during home tec and at home witness by her older sisterand at home witness by her older sister
School refuse to have her back unless School refuse to have her back unless “some things is done”“some things is done”
Mother is sleeping in her bedroom on the Mother is sleeping in her bedroom on the floorfloor
EEG –non specfic changes has occasional EEG –non specfic changes has occasional spikesspikes
MAXMAX
4 years of age- 8 daily episodes cries sits down goes rigid eyes roll 4 years of age- 8 daily episodes cries sits down goes rigid eyes roll back lasting 2mins then confused afterwards for a bout 30mins.back lasting 2mins then confused afterwards for a bout 30mins.Described as paleDescribed as paleMax says he feels dizzy before hand.Max says he feels dizzy before hand.Neurodevelopmental normalNeurodevelopmental normalNo other reported problems – absence episodes reported by the No other reported problems – absence episodes reported by the nursery but not noted at home nursery but not noted at home PMH – sinus bradycardia as neonate seen by Cardiologist at GOS PMH – sinus bradycardia as neonate seen by Cardiologist at GOS happy with him happy with him Examination normal HR 70 nil else Examination normal HR 70 nil else Echo normal Echo normal ECG normalECG normalNormal QTc -0.44secNormal QTc -0.44sec 24hour tape mum went to anyway not cancelled24hour tape mum went to anyway not cancelled
Differential diagnosis of a Differential diagnosis of a seizureseizure
Syncope- VasovagalSyncope- Vasovagal Cardiac causes- cardiomyopathy/prolonged QTcCardiac causes- cardiomyopathy/prolonged QTcBreath holdingBreath holdingReflex anoxic seizures/ Reflex anoxic syncopeReflex anoxic seizures/ Reflex anoxic syncopePsuedo sezuiresPsuedo sezuiresEmotional syncopeEmotional syncopeValsalva/ constipationValsalva/ constipationStereotypical behavioursStereotypical behavioursTics Tics Gratification habitsGratification habitsBasilar migraineBasilar migraineParoxysmal spasmodic torticollisParoxysmal spasmodic torticollisBenign paroxysmal vertigoBenign paroxysmal vertigo
TAKE A HISTORY THE EVENT AND THE TAKE A HISTORY THE EVENT AND THE RUN UP AND AFTER.RUN UP AND AFTER.
If your not sure adopt watchful waiting DO If your not sure adopt watchful waiting DO NOT order an EEG unless you think it will NOT order an EEG unless you think it will give you information and interoperated the give you information and interoperated the information with the clinical caseinformation with the clinical case
Give advice Give advice
1. What are the risk for a reoccurrence after one seizure? After two seizures?2. What should you tell them to do at school?3. Whats the advice regarding swimming?4. Whats the advice about sleeping arrangements?5. Whats to do about TV and computer games?6. Any other advice?7. You reg wants to give them Midazolam prescribe it?
Is the episode a seizures?Is the episode a seizures?
What’s the cause of the seizure?What’s the cause of the seizure?
Is this epilepsy?Is this epilepsy?
What is the cause of the epilepsy? ---------- What is the cause of the epilepsy? ---------- NOW think EEGNOW think EEG
Classify epilepsy into a syndrome?Classify epilepsy into a syndrome?
www.stars.org.ukwww.stars.org.uk
www.epilepsy.org.uk/infowww.epilepsy.org.uk/info
Epilepsy advice and informationEpilepsy advice and informationWhat is epilepsy?What is epilepsy? Caring for a baby or young child when you have epilepsy: a detailed guideCaring for a baby or young child when you have epilepsy: a detailed guide ChildrenChildren Depression and epilepsyDepression and epilepsy Developing epilepsy in later lifeDeveloping epilepsy in later life Disability Discrimination Act (UK)Disability Discrimination Act (UK) Driving and epilepsyDriving and epilepsy EducationEducation Entitlements and benefits for people with epilepsyEntitlements and benefits for people with epilepsy Epilepsy and learning disabilitiesEpilepsy and learning disabilities Epilepsy and Travel abroadEpilepsy and Travel abroad Epilepsy information for prisonsEpilepsy information for prisons Epilepsy, osteoporosis and osteomalacia Epilepsy, osteoporosis and osteomalacia Flu and epilepsy Flu and epilepsy Getting a diagnosis Getting a diagnosis Identity jewellery Identity jewellery Inheritance Inheritance Living with dificult to control epilepsy Living with dificult to control epilepsy Me and my dadMe and my dad