Headaches - Paediatric Neurology

Headaches

·        History: 

o   Pain characteristics: how bad, do they vary from one to the next, throbbing (migraine)/tight (tension)

o   Auras: visual, unilateral slowly spreading tingling/numbness/weakness

o   Photo & phonophobic 

o   Look pale/unwell ®?migraine

o   Late afternoon ®? hypoglycaemic

o  Suspect ­ICP if vomit in the morning (without much nausea), increasing severity, or wake in the morning or at night with a headache 

o  Stress: relationship to headaches to school and holidays

o  Relieving factors: Sleep, medication

o  Associated with migraines:

§  Motion sickness – patient and family

§  „Ice-cream‟ headaches – like shooting pain into head when biting an ice-block 

§  Benign Paroxysmal Vertigo of Infancy (not the same as adult BPPV): 2 – 3 minute episodes of unsteadiness, queasiness, nystagmus

§  Cyclical vomiting

§  Abdominal migraine 

o  Past Medical History: head injury. To assess severity ask: did he loose consciousness, did he go to hospital and stay overnight, have any stitches or need imagining 

o  Family history: 

§  What kinds of headaches do the rest of the family get (don‟t talk about migraine – different meanings to different people)? There is a family history in 80% of migraine sufferers

§  Serious neurological disorders, strokes

·        Exam: 

o  General: Well/unwell, growth (if big head then measure parents), dysmorphic features, skin (stigmata)

o  BLOOD PRESSURE

o  ­ICP: ¯venous pulsations in retinal veins, papilloedema, ¯visual acuity, 3^rd and 4^th nerve palsy

o  Focal neurological signs: especially cerebellar (common site of lesion in kids 2 – 10) 

o  Cranial bruit to check for AVM: common finding. Interested in asymmetry, or if it can be eliminated by compressing the ipsilateral carotid artery 

o  Check sinuses, teeth, TMJ

·        Differential:

o  Is it acute or chronic, recurrent or progressive, etc 

o  Migraine: normally throbbing. ­when stressed.  Most common cause in children 

o  Tension headache: Rare before adolescence. Presentation: constant daily bilateral headaches without well defined onset and ending, less impairment of function. Stress (ie doesn‟t differentiate from migraine. But children usually somatise rather than tense up). More common in older girls 

o  ­ICP

o  Drugs: eg daily use of analgesics

·        Management:

o  Reassure: most parents seek help to check its not serious 

o  Education: Migraines are familial, due to ischaemia and vasodilation (which stretches pain fibres in blood vessels)

o  Symptom diary: check for food association (fairly rare)

o  Avoid triggers

o  ?Psychologist referral: 

§  ¯Stress, get to the bottom of stress problems, relaxation, coping

§  It will be life long – learning skills to cope better than life long medication

o  Medication: 

§  Paracetamol: need a big dose and right at the start to make a difference (otherwise ¯gastric motility and fail to stop spread) 

§  Propranolol: tested in RCT, but not if asthmatic

§  Ergotamine: contraindicated if complex migraine (focal neurological signs)

·        Migraine Definition:

o  Recurrent paroxysmal headaches with pain free intervals with normal health, plus two of:

o  Unilateral pain, nausea, visual or other aura, family history in parents or siblings