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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 Tension type Headaches Secondary Many causes • General • Focal • Recurrent – Chronic • Progressive • Non progressive Classification -acute • Acute General – – – – – – – – – Fever/ infection CNS inf Postictal BP Hypoglycemia LP Head injury CNS bleed Embolus • Acute Focal – – – – – – – Sinusitis Otitis Pharyngitis Glaucoma TM joint Dental Occipital neuralgia – Trauma Acute Recurrent -Migraine -Vasculitis -AVM -Substance abuse -Post ictal -Shunt related Classification -chronic • Chr Progressive – – – – – – – – Hydrocephalous Subdural haematoma Neoplasm Abscess Dandy-walker Chiari malformation Subdural empyoema IIH • Chr non-progressive – – – – Chr tension type Chronic daily migraine New persistent daily Hemicrania continua How does headaches occur? (Pathophysiology) • Sensitive extracranial structures – – – – – Skin, S/C tissues Muscles Mucous membranes Teeth Larger vessels • Sensitive intracranial structures – Vascular sinuses – Large veins – Dura around the sinuses, arteries, base of brain Inflammation, irritation, traction, dilatation of these structures 5th, 7th, 9th 10th, upper cervical Refer to face, top of head, back of the head, neck Pathophysiology • Migraine – Vascular theory • Cerebral ischaemia – aura • Extracranial vaso dilatation – pulsating head ache – Trigemino-vascular theory • Depolarisation of cortical neurons • Tension type – Genetic – Muscle mechanisms – Central/peripheral sensitization – Unclear • Cluster Headache -Hormones -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. B. C. At least 5 attacks of B-D Head ache lasts 1-48hrs 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 inferotemporal 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 • Antihistamines Prophylactic – 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