Headaches in children

& New NICE Guidance

Sreeni Tekki-Rao
April 2014
 Content
• Quiz
• Classification
• Pathophysiology
• History and physical exam
• Primary headaches
• NICE approach
 Incidence & Prevalence
Incidence per 1000 Males Females

Migraine with aura 6.6 14

Migraine without aura 10 18

Headaches Age <7yrs 7-15

Prevalence 37-51% 57-82%

Serious underlying disease: 3/815 children with

headaches
 Classification

Migraine Clinical (Practical)

– Acute
Primary Cluster • General
• Focal
Tension
Headaches • Recurrent
type
– Chronic
Secondary • Progressive
Many • Non progressive
causes
 Classification -acute

• Acute General • Acute Focal Acute Recurrent

– Fever/ infection – Sinusitis -Migraine
– CNS inf – Otitis
– Postictal – Pharyngitis -Vasculitis
– BP – Glaucoma -AVM
– Hypoglycemia – TM joint
-Substance abuse
– LP – Dental
– Head injury – Occipital -Post ictal
– CNS bleed neuralgia -Shunt related
– Embolus – Trauma
 Classification -chronic
• Chr Progressive • Chr non-progressive
– Hydrocephalous – Chr tension type
– Subdural haematoma – Chronic daily migraine
– Neoplasm – New persistent daily
– Abscess – Hemicrania continua
– Dandy-walker
– Chiari malformation
– Subdural empyoema
– IIH
 How does headaches occur?
(Pathophysiology)

• Sensitive extracranial structures Inflammation,

– Skin, S/C tissues irritation, traction,
– Muscles dilatation of these
– Mucous membranes structures
– Teeth
– Larger vessels 5th, 7th, 9th 10th, upper
• Sensitive intracranial structures cervical
– Vascular sinuses
– Large veins
– Dura around the sinuses, arteries, Refer to face, top of
base of brain head, back of the
head, neck
 Pathophysiology
• Migraine • Tension type
– Vascular theory – Genetic
• Cerebral ischaemia – aura – Muscle mechanisms
• Extracranial vaso – Central/peripheral
dilatation – pulsating sensitization
head ache – Unclear
– Trigemino-vascular
theory • ClusterHeadache
• Depolarisation of cortical -Hormones
neurons
-Hypothalamus
-Cingular cortex
 Genetics and headaches
• Classic Migraine: First degree relative
• Migraine without aura: Multifactorial
• Familial hemiplegic migraine: AD
– Mutations voltage gated ca+ channels
• CACNA1A, ATP1A2
 Evaluation
• How many types of headache?
• When did it start (Duration)
• How did it begin?
• How often do they occur?
• Becoming more severe?
• Does anything special bring them
on?
• Can you preempt 15-30 min
before?
• Where is the pain?
• What does your pain feel like?
• What do you do when you get
one?
• What makes it worse/better?
• Do you take anything?
• How long does it last?
• Has any other family member got
it?
• Any other medical problems?
• Are you taking any medications
regularly?
• Any neurological symptoms in
between headaches?
• How many days of school missed?
• How often do you take medicine to
relieve headache?
• What do you think is causing this
headache?
 Enquire…
• Sx of raised intracranial pressure
• Progressive neurological disease
• Quality of life
• Impact on daily activities
• Educational performance
• Change in behaviour/personality
Clarify..
Terms: “Throbbing”, “Pulsatile”
Concept: Five sides to head?
 Physical exam
• General:
– Temp, BP, short stature, NC markers
– Tenderness over scalp/skull
• Neuro
– Nuchal regidity
– Trauma signs
– OFC
– Bruits
– Motor eye movements
– Fundus
– Symmetry of reflexes
– Fogg test
 Red Flag features
• Headache worse in recumbency, or with
cough/strain
• Headache waking up child
• Confusion +/- morning nausea or vomiting
• Recent change in personality, behavior,
educational performance
• Physical signs: field defect, short stature,
cranial bruit, raised ICP
 Scenario 1

• Intermittent headaches
• Nausea, vomiting
• Pain free intervals
• No neuro symptoms/signs
• +ve family history similar headaches

Migraine
 Scenario 2

• Relatively short history

• Worsening headaches over time
• +ve neuro symptoms and signs

Chronic Progressive
Headache
Investigate!!
 Scenario 3

• Severe headache
• Appears to be not in stress due to headache
• No raised ICP features
• Normal neuro exam

Chronic non
progressive (tension type)
 Episodic Migraine
• Episodic, Periodic,
paroxysmal
• Throbbing
• Uni/bilateral
• Duration: 30min to days
• Attacks separated by pain
free intervals
• Pallor, beh changes
• Relieved by sleep
• Boys>girls (before
teens)
• Begins early in life
• Teenagers
– Early morning
– Awakening the child
• Young kids
– mid afternoon
 Migraine with aura (Classic)
• Aura
– Nausea, vomiting, abd pain
– Visual disturbances
• Scotoma moving across fields
• Blurring, hemianopia
• complete blind in one eye (amurosis fugax)
– Numbness, tingling in one arm/side
– Hemiplegia
– Aphasia, apraxia
Aura
 Criteria
• Migraine with Aura (Classic) – 17%
– At least 2 attacks lasting 1-72 hours
– Migraine aura
– Not attributed to another cause
• Migraine without aura (Common) – 60%
A. At least 5 attacks of B-D
B. Head ache lasts 1-48hrs
C. Headache has at least 2 of
a. bilateral/unilateral (frontal/temporal)
b. Pulsating
c. Moderate to severe
d. Aggravated by routine physical activity
D. During headache
a. Nausea and/or vomiting
b. Photophobia and /or phonophobia
 Complicated migraine
• Basilar artery migraine
• Hemiplegic
• Ophthalmoplegic
• Migraine variants
– Benign paroxysmal vertigo
– Benign paroxysmal torticollis
– Abdominal migraine
– Cyclical vomiting
 Basilar artery migraine
• Dysfunction of
– brain stem, cerebellum, parieto-occipital and infero-
temporal cortex
• C/F:
– Preceded by Vertigo, tinnitus, dysarthria, ataxia,
diplopia
– Blurred vision, tunnel vision, visual field defects,
parasthesia, dizziness, hemipareisis, quadriperesis,
aphasia, loss of conciousness
– Headaches not severe – occipital
• Duration 1-several hrs
• Recovery complete
• Common in females
 Other headache syndromes
• Occipital neuralgia: uni/bilat posterior, infrequent to
continuous
• Temporal mandibular joint: Dull aching pain
unilateral below ear
• Exertional headache: Cough, sneeze, laugh, sports
• Hemicrania Continua: steady, severe, frontal, no
nausea, response to indocid
• Ice cream headache: Cold induced
• Ice pick headache: single sharp jabbing over
orbit/temple/parietal
 Chronic Tension-type
• No aura, Less severe
• Bifrontal/ bitemporal, nonsepcific description
• Rarely: Nausea/vomiting
• Mild blurring, fatigue,dizziness
• Frequency: 15 times/month
• Normal neurology
• Excessive school absence, overuse of analgesics
 Cluster Headache
• Episodic/Chronic
• Episodic: Frequent last 1-3months with remission
months to yrs
• Chronic: >1 yr with out remission
• Males>females, not common in children
• Attack: typical 10min-3hrs, waking from sleep,
unilateral, around eye, lacrimation, rhinorrhoea,
nasal stuffiness, ptosis/miosis
Cluster headache
 Investigations – if appropriate
• CT head
• Fundus/perimetry by ophthalmologist
• MRI
• MRV/MRA
• LP/Infusion study
• Psychological evaluation
• EEG – Not recommended if migraine is
suspected (AAN)
 Management all headaches-NICE
• Headache diary -8weeks
• Investigate
– if red flags
– No neuroimaging, if primary headache is diagnosed
• Discussion with pt/parents
– Positive diagnosis
– Options of treatment
– Recognition that it is a valid medical disorder
– Written information
– Explain risk of medication
 Migraine Treatment
• Phramacologic vs Non pharmacologic
• Symptomatic vs Prophylactic
• Rx depends
– Age
– Severity
– Frequency of attacks
– Attitude for Rx
– Assurance may suffice
 Non pharmacologic Rx
• Patient/parent education
• Eliminating triggers (cows milk, egg,
chocolate, orange wheat, benzoic acid,
cheese, tomatos, rye)
• Regular diet, sleep, exercise
• Counseling
• Biofeedback
 Symptomatic Rx
• NSAID most useful than paracetamol
– Ibuprofen, Naproxen, Phenacetin, Caffeine
• Triptans (Sumatriptan spray) – not licenced
• Antiemetics
(Cyclizine,domperidone,ondansetran)
• Sedatives
• Ergotamines – not children
 Prophylactic
• Antihistamines
– Cyproheptadine
• H2 and serotonin receptor antagonist
– Pizotifen
• Betablockers
– Propranolol (1 mg/kg up to 10mg BD)
– Atenolol (0.8-2mg/kg/day)
• TCA (Amitryptiline)
• Anticonvulsants
– Valproate, Topiramate (50-100mg), Levetiracetam (1g)
• Calcium channel blockers
– Verapamil, Nifedipine, Flunarazine (5 mg/day)
 Evidence for prophylaxis
• Pizotifen
– RCT placebo crossover, 47 children, 7-14yrs
– Did not reduce number of episodes, mean
duration
• Propronolol
– 3 trials placebo controlled (1 effective, 2 no
difference, 3 not effective)
– Systematic review (58 trials of all ages) – more
effective than placebo
 NICE guidance - migraine
• Acute Rx
– Oral triptan + NSAID/Paracetamol
– Children 12-17yrs – Nasal Triptan
– Antiemetic (even in the absence of nausea)
• If vomiting severe rectal
– Do not offer Ergots
• Prophylaxis
– Discuss benefits and risks
– Offer Topiramate/propranolol
– Alternatives: 10 sessions of acupuncture/gabapentin
– R/v in 6 months
 Useful tips
• Acute attack:
– Rest – antiemetic – sedative (diphen hydramnine) –
Analgesic (NSAID)…
– 2 hr later: Rpt sedative, different analgesic…
– If failed above: Triptans
• Prophylactic:
– Frequent migraine unresponsive to acute measures
– Disruptive to school/other activities
 Life style issues
• BNF: avoid common headache triggers
– Heat, light, noise, strong smell, lack of sleep, lack
of food, excitement, travel, exercise, types of food
• Fluctuating vulnerability
• Use common sense
 Tension type headache – NICE Rx
• Acute Rx
– Aspirin/Paracetamol/NSAID
– No opioids
• Prophylaxis
– 10 sessions of acupuncture over 5-8 weeks
 Cluster – NICE Rx
• Acute Rx
– O2
• 100% o2 via non-rebreathing mask @12l/min
• Home O2
– S/c or Nasal Triptan
– DONT offer
• Paracetamol, NSAIDs, opoids, ergots, oral triptans
• Prophylaxis
– Verapamil
– If unsure contact specialist
 Medication overuse headache
• Consider in those taking drugs
>3mo
– 10days/mo or more of following
• Triptans, Opioids, ergots, combination
analgesics
– 15 days/mo or more of following
• Paracetamol, Aspirin, NSAID or combi
• Rx: Stop for at least 1mo
– Likely to get worse before
improvement
– Offer appropriate prophylaxis
– R/V in 4-8wks
 Rational Approach
• Careful clinical assessment
• Simple understandable explanation
– Common, benign, biological phenomenon
– Don’t confuse with terminology such as Tension
headache/complicated migraine/scientific terms
• Investigate sensibly if red flag signs
• Acute attacks: Simple analgesia early, with antiemetic
• Prophylactic: for truly intrusive
 Prognosis - migraine
• Excellent
• Mostly does not interfere with school
• 70% persist into adult life
• Longer periods free of symptoms
• Status migrainosus
– >72hrs/ >24hrs of diasbled
– Rx: sedation, IVF, ergotamine
Questions?
 Summary
• Headaches are just primary or secondary
• Careful history and evaluation to rule out
serious causes (rare)
• Remember NICE approach for diagnosis
• Explanation in simple terms & reassurance
• Offer treatment and prophylaxis
• Remember medication overuse headaches
 References
• Childhood Headache;
– R Newton, Arch Dis Child Educ Pract Ed 2008;
93:105-111
• Headaches and Nonepilpestic Episodic
Disorders;
– A. David Rothner and John Menkes
Child Neurology 7th ed, chapter 15, pg 943-959
• Headaches; NICE clinical guideline 150; Issued
Sept 2012
THANK YOU