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Headaches in Children and young People CLINICAL GUIDELINES Register No: 14037 Status: Public Developed in response to: Contributes to CQC Outcome number: Guideline Review 4 Consulted With Alison Cuthbertson/ Miss Rao Mahesh Babu Manas Datta Aloke Agrawal Muhammed Ottayil Sharmila Nambiar Sharon Lim Ahmed Hassan Brian McConville Mel Hodge Andrea Stanley Sarah Moon Professionally Approved By Post/Committee/Group Clinical Director for Women’s, Children’s and Sexual Health Directorate Paediatric Consultant Paediatric Consultant Paediatric Consultant Paediatric Consultant Paediatric Consultant Paediatric Consultant Paediatric Consultant Lead Nurse Senior Sister, Phoenix Ward Clinical Facilitator Children’s Acute Care Specialist Midwife Guidelines and Audit Date November 2014 November 2014 Dr Ottayil Consultant Paediatrician with special interest in Neurology Version Number Issuing Directorate Ratified by: Ratified on: Executive Management Board Sign Off Date Implementation Date Next Review Date Author/Contact for Information Policy to be followed by (target staff) Distribution Method Related Trust Policies (to be read in conjunction with) Document Review History Version Number Reviewed by 1.0 Victoria Machell 1.0 Children’s and Young People Service DRAG Chairmans Action 23rd November 2014 December 2014 23rd November 2014 November 2017 Victoria Machell, Paediatric Nurse All Clinicians Hard copies on ward Intranet & website 04072 Hand hygiene 04064 Safeguarding Children Children’s Early Warning Tool (CEWT) Review Date 23rd November 2014 1 Index 1 Purpose 2 Equality and Diversity 3 Definitions 4 Assessment 5 Diagnosis 6 Management 7 Staff Training 8 Audit and Monitoring 9 Communication 10 References Appendix A – Headache Algorithm 2 1.0 Purpose 1.1 To Promote Best practice in the Diagnosis and Treatment of Headaches. Following the NICE Guidelines 1.2 To ensure that all children cared for by Mid Essex Hospital Services NHS Trust are treated using best practice 1.3 To ensure that each child is listened to and their rights respected 1.4 To evaluate the Child who presents with Headache and consider the need for further treatment or referral 2.0 Equality and Diversity Mid Essex Hospital Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Definitions Headache disorders have 2 main classifications, these are Primary and Secondary type. 3.1 Primary Headaches These are the most common and are categorised as: Tension-type headache Migraine Cluster headache 3.2 Secondary Headaches These are caused by underlying disorders such as: Medication overuse Giant Cell Arthritis Raised Intercranial Pressure Infection 4.0 Assesment 4.1 Children who present with headaches who have any of the following features require a consideration for further investigation and or referral to a specialist. Worsening headache with Fever Sudden onset with maximum intensity reached within 5 minutes New-onset neurological deficit New-onset cognitive dysfunction Change in personality Impaired level of consciousness Recent head trauma (within 3 months) Headaches triggered by coughing, sneezing or breathing through a blocked nose Headaches triggered by exercise Orthostatic headache (triggered by changes in posture) Substantial changes in characteristics of headaches Compromised immunity History of malignancy 3 History of brain malignancy or metastasise brain malignancy Vomiting without obvious cause 4.2 Consider Headache Diary for a minimum of 8 weeks asking the patient or family to record frequency, duration, severity of the headaches and any associated symptoms. Ask them to also note any medication used to relieve the headache. If appropriate ask them to note the relationship between headaches and the menstruation cycle. 5.0 Diagnosis 5.1 Tension type Headaches Table Diagnosis of tension-type headache, migraine and cluster headache Headache Tension-type feature headache Migraine (with or without Cluster headache aura) Pain location1 Bilateral Unilateral or bilateral Unilateral (around the eye, above the eye and along the side of the head/face) Pain quality Pressing/tightening (non-pulsating) Pulsating (throbbing or banging in young people aged 12–17 years) Variable (can be sharp, boring, burning, throbbing or tightening) Pain intensity Mild or moderate Moderate or severe Severe or very severe Effect on activities Not aggravated by Aggravated by, or causes routine activities of daily avoidance of, routine living activities of daily living Other None symptoms Unusual sensitivity to light and/or sound or nausea and/or vomiting Restlessness or agitation On the same side as the headache: Aura 2 Symptoms can occur with or without headache and: red and/or watery eye nasal congestion and/or runny nose are fully reversible develop over at least 5 minutes forehead and facial sweating last 5−60 minutes. constricted pupil and/or drooping eyelid swollen eyelid Typical aura symptoms include visual symptoms such as flickering lights, spots or lines and/or partial loss of vision; sensory 4 symptoms such as numbness and/or pins and needles; and/or speech disturbance. Duration of 30 minutes–continuous 4–72 hours in adults 15–180 minutes headache 1–72 hours in young people aged 12–17 years Frequency < 15 days ≥ 15 days of per month per month headache for more than 3 months Diagnosis Episodic tensiontype headache 5.2 < 15 days per ≥ 15 days per month month for more than 3 months Chronic Episodic tensionmigraine type (with or headache 5 without aura) 1 every other day to 8 per day3, with remission4 > 1 month Chronic Episodic migraine 6 cluster (with or headache without aura) 1 every other day to 8 per day3, with a continuous remission4 <1 month in a 12-month period Chronic cluster headache Migraine Aura Aura should be suspected in people with neurological symptoms that are fully reversible and develop gradually and last for between 5 and 60 minutes. 5.2.1 Diagnosis of migraine with aura patients with or without headache that meet one or more of the typical symptoms which are: Visual symptoms that may be positive e.g. flickering lights, spots or lines and or negative e.g. partial loss of vision. Sensory symptoms that may be positive e.g. pins and needles or negative e.g. numbness Speech disturbance 5.2.2 Further investigation and referral may be considered in children who present with atypical symptoms such as motor weakness or double vision or visual disturbance affecting one eye or poor balance or decreased level of consciousness. 5.3 Menstrual related Headaches These types of headaches should be suspected in girls whose migraine occurs between 2 days before and 3 days after the start of the menstrual cycle in at least 2 out of 3 cycles. Diagnosis of this is best done using a headache diary. 5.4 Medication overuse 5 Be aware of children whose headaches develop or worsen while they are taking the following drugs for 3 or more months. Triptans, opioids, ergots or combination analgesic medications on 10 days per month or Paracetamol, aspirin or and NSAID, either alone or in combination on 15 days per month or more. 6.0 Management 6.1 Using a headache diary to record frequency, duration and severity of headaches. Use of the diary should also monitor effectiveness of interventions and form a basis for discussion. 6.2 Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance. 6.3 written and oral information about headache disorders including information about support organisations much be given to families and young people. 6.4 Consider paracetamol, and /or NSAID for tension type headaches. Do not offer opioids for the acute treatment of tension type headaches. 6.5 Consider nasal triptan for children over 12 years. Children under 12 use NSAIDS and paracetamol. Consider an anti-emetic in addition to other acute treatment of migraine even if nausea and vomiting are not present. 7.0 Staff Training 7.1 All medical and nursing staff are to ensure that their knowledge, competencies and skills are up to date in order to complete their portfolio and appraisal. 7.2 During induction all staff will receive instruction on current policies and guidelines and how to access them. 7.3 Staff will regularly receive updated guidelines to read. 8.0 Audit and Monitoring 8.1 Where a Patient’s notes have demonstrated that the appropriate action has not been taken then a ‘DATIX’ form is to be completed. This will highlight further staff training needs. 8.2 A quarterly DATIX audit will be examined by the Lead Nurse and the clinical director and risk lead for CYP 8.3 Where a child’s notes have demonstrated that the appropriate action has not been taken a ‘risk event form’ is to be completed. This will address any further training needs for staff that require updating. 8.4 Audit of compliance with this guideline will be considered on an annual audit basis in accordance with the Clinical Audit Strategy and Policy, the Women’s and Children’s Directorate annual audit work plan and the NHSLA/CNST requirements. The Audit Lead in liaison with the Risk Management Group will identify a lead for the audit. 6 8.5 The findings of the audit will be reported to and approved by the Risk Management Group and an action plan with named leads and timescales will be developed to address any identified deficiencies. Performance against the action plan will be monitored by this group at subsequent meetings. 8.6 Key findings and learning points from the audit will be submitted to the Patient Safety Group within the integrated learning report. 8.7 Key findings and learning points will be disseminated to relevant staff. 9.0 Communication 9.1 Ratified guidelines will be uploaded to the intranet and website. 9.2 It is the responsibility of the author to ensure that all clinical staff working with children are individually notified by email 10.0 References www.nice.org.uk www.uhbristol.nhs.uk/ Appendix A headaches algorithm.pdf 7