Download Headache ‘THE RED FLAGS’

Headache
‘THE RED FLAGS’
Edward Kija
Department of Paediatric Neurology
Red Cross War Memorial Children’s Hospital
University of Cape Town
Outline
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Epidemiology
Classification
Diagnostic Criteria
Primary Headaches
Secondary Headaches
Management
Conclusion
Introduction
• Common cause of referral to Neurology
• Prevalence: Range 30.1 to 53.2%
• Recurring headache
– 3% for 7 years old
– 15% for 15 years old
– Before puberty: Boys > Girls
– After puberty : Girls > Boys
Cvetkovic VV et al 2014, Herwig KB et al 2007, Laurell et al 2004, Sillanpaa et al 1983
Pathophysiology
Clinical Approach
Acute Generalized
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Fever
Systemic Infection
CNS Infection
Toxins: Lead, CO
Post ictal
Electrolyte Imbalance
HT
Post LP
Trauma
Intracranial Hemorrhage
Vasculitis
Acute Recurrent
Chronic Progressive
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Brain Tumour
Idiopathic intracranial hypertension
Brain abscess
Subdural hematoma
Hydrocephalus
Hemorrhage
Hypertension
Vasculitis
Endocrine diseases: Thyroid or Parathyroid
Chronic Non-progressive
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Chronic daily headache (chronic migraine)
Chronic tension type
Chronic Hemicrania continuum
Conversion disorder
Malingering
After concussion
Depression
Anxiety
Adjustment reaction
ICHD-3 Migraine
ICHD-3 TTH
Migraine-Diagnostic Criteria
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Migraine with an aura- Diagnostic Criteria
Episodic TTH
Chronic Headache
• ≥ 15 headache days per month
• Chronic Migraine
– Episodic Migraine-becomes persistent
• Chronic TTH
– Should not have Hx of Episodic Migraine
– Occasionally difficult to differentiate from Chronic
Migraine
• Newly Persistent Daily Headache
– New headache becomes daily within 3 days
– Not caused by another disorder
– Evaluation for secondary causes
– Triggers: Viral illness, minor head trauma, surgery
Trigeminal Autonomic Cephalalgia
• Rare in children
• Treatment for Migraine and TTH may not be
effective
– Cluster Headache
– Paroxysmal hemicrania
– SUNCT : Short lasting Unilateral Neuralgiform
headache attacks with Conjuctival injection and
Tearing
• Autonomic symptoms
Secondary Headaches
• Elevated Intracranial Pressure
– Causes:
• Hydrocephalus: SOL, Aqueduct stenosis, Impaired CSF
absorption
• Increasing the volume of tissues in the cranial vault:
Mass lesions, edema, hemorrhage, inflammation
– Symptoms:
• Progressive, night time awakening, worse on valsalva,
exertion, persistent vomiting, lethargy, personality
change
• Cranial nerve palsy (III, IV, VI), Papilledema
Idiopathic Intracranial Hypertension
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Incidence: 3.9-19 per 100,000
Common in Females
Transient visual disturbance
Presence of papilledema
Elevated CSF opening pressure ≥25cmH2O
Risk Factors:
– Obesity
– Endocrinopathies: Hypothyroidism, Addison’s disease, Oral
steroids etc
– Medications: Tetracycline, oral contraceptive
– Vitamin A intoxication, Anaemia
– SLE, Chronic sinopulmonary infection
Infection
• Acute viral illness
– Common cause of pediatric headache
• Systemic infections
– Sepsis
– Streptococcal pharyngitis
– Meningitis
– Encephalitis
Structural Disorders
• Brain Tumour
• Large Arachnoid Cysts
• Vascular Malformation
– Mass effect, Hemorrhage
• Neurocutaneous Syndrome: TSC, NF-1
• Chiari I Malformation
– Cerebellar tonsils >5mm
– Symptoms: Occipital headaches, Cough headaches,
sensory disturbance, weakness, ataxia, cranial nerve
dysfunction
– >30% asymptomatic despite radiological confirmation
The RED FLAGS
Other Causes….
• Vascular Disorders
– ICH, Stroke, SVT
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Trauma
Hypertension
Epilepsy
Psychiatric Disorders: Depression , Anxiety
– Exacerbating factor
• Hypothyroidism
• Rheumatologic Disorders
Evaluation of a Child with Headache
Evaluation…
• History
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Characterization
FHx
Social Hx
Life Style:
• Sleep
• Caffeine intake
• Exercise
• Physical Examination
– Neurocutaneous Syndromes
• Headache Diary
Pain Scales
The Role of EEG
The Role of Neuroimaging
Other Testing
• Suspicion of an underlying disorder
– Meningitis
– Thyroid disease
– Other systemic disease
• Suspicion of raised ICP and neuroimaging is
normal
– LP with opening pressure
– CSF indices
Management
Acute Management
Preventive Therapies
Conclusion
• Most pediatric headache are due to:
– Benign illness, Primary headache syndrome
• Recognize disorders causing secondary
headache
• Failure: Prolonged morbidity and even
mortality
• Proper Evaluation and Management