Download Headache Education

Headaches and Head Injuries in Children
and Adolescents
Texas Children’s Hospital Advanced Practice Provider Conference
February 7, 2014
Deanna Duggan, MS, RN, CPNP-PC,
PMHS
Headache Clinic
Blue Bird Circle Clinic for Pediatric Neurology
Texas Children’s Hospital
Baylor College of Medicine
Objectives
1. Identify clinical presentation of primary and secondary
headaches
2. Identify up to date recommendations for management
of secondary headaches attributed to head injury
3. Assimilate medical and psychological interventions
4. Enable the pediatric provider how to construct an
individualized headache treatment plan
Overview
• Incidence and prevalence in the
pediatric population
• Degrees of disability
• Types
• Accurate diagnosis is key
• International Headache Society
Classification
www.ihs-classification.org/en
• Concussion vs. Traumatic Brain
Injury
Examples of headache types described in ICHD-2
Part I: The Primary Headaches
• Tension-type Headache
• Migraine (with or without aura)
• Cluster Headaches and other Trigeminal Autonomic Cephalalgias
Part II: The Secondary Headaches
• Headache Attributed to Head or Neck Trauma
Acute Post-Traumatic Headache
Chronic Post-Traumatic Headache
Acute Headache Attributed to Whiplash Injury
Post-craniotomy Headache
• Medication Overuse Headache
• Cervicogenic Headache
Part III: Cranial Neuralgias, Primary and Central Causes of Facial Pain
Evaluate
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Characteristics of the headache and headache pattern
Baseline headache
Is there resolution of symptoms in-between headaches?
Consider other disorders or triggers
Mechanism of injury
Concussion: Describe symptoms reported immediately after
injury and days subsequent to injury
Is there a concussion history?
What makes the headache better or worse?
Physical and Neurological exam (including fundoscopy)
Neuroimaging
Red Flags in the Diagnosis of Childhood
Headaches
• Escalating frequency and/or severity of headaches over several weeks
(under 4 months) in a child under the age of 12, and even more importantly
under the age of 7
• A change of frequency and severity of headache patterns in young children
• Fever is not a component of migraine at any age, especially in children
• Headaches accompanied by seizures
• Sensory disturbance may occur in certain forms of migraine, however,
neurological attention is warranted to determine appropriate assessment
and intervention
Symptomatology
Post concussion symptom checklist
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Headache
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Nausea/vomiting
Balance problems
Dizziness
Sensitivity to light
Blurred vision
Sensitivity to noise
Nervousness
Numbness/tingling
Feeling ‘slowed down’
Feeling like ‘in a fog’
Difficulty concentrating
Difficulty remembering
Neck pain
Fatigue/drowsiness
Difficulty sleeping
Sadness
Irritability
*Symptoms are subjective*
- 38% of athletes reporting no symptoms
may still demonstrate neurocognitive deficits
(Broglio, 2008)
Define a concussion
• Symptoms that may occur
after injury to the head include
at least one of the following:
Any period of loss of
consciousness, any loss of
memory for events
immediately before or after
injury, alteration in mental
state at the time of injury
and/or focal neurological
deficits that may or may not be
transient
• Symptoms that may persist
after injury:
1. loss of memory or AMS
(dazed, disoriented, confused)
2. physical symptoms
(nausea, vomiting, dizziness,
HA, tinnitus, blurred vision,
sensory loss, sleep
disturbance or extended
periods of fatigue/lethargy)
3. cognitive deficits (attention,
concentration, language,
memory, perception)
Examination
1. Observe:
Aphasia or speech difficulty
Behavior
2. Palpate:
Head and neck for painful/tender
areas, swelling or crepitus
3. Assess:
Neck ROM (active and passive)
Neck strength
Dermatomes and myotomes
4. Stress tests
3 Cs:
Cognition
Coordination
Cranial nerves
Cognitive Screening Tools
SCAT2
SAC (sideline mental status tests)
CNS Vital Signs
CogSport
HeadMinder
ImPACT
Sports as a Laboratory Assessment Model (SLAM)
Automated Neuropsychological Assessment Metrics
• Serial evaluations
• Neuropsychological evaluation
What is cognitive “rest”?
• Safety Guidelines :
1. Restrict physical activity until all symptoms COMPLETELY resolved
2. Risk for “Second Impact Syndrome” (repeat concussion that occurs
soon after initial concussion) - Result can be a rapid, catastrophic increase
in pressure within the brain. Effects include physical paralysis, mental
disabilities, and epilepsy. Death may occur approximately 50% of the time.
3. Plan for educational modifications specific to the patient per section 504
Other Health Impairment – Traumatic Brain Injury
* extended time to complete schoolwork or testing
* testing in a separate room with decreased environmental stimulation
* extended time to walk in-between classrooms, have small frequent
meals, carry a water bottle and liberal bathroom privileges
* allow for the patient to stop any educational activity should severe
headache or other neurological symptoms exacerbate. In such case, child
should be excused immediately
* partial attendance or homebound
Traumatic headache/Concussion treatment: Key factors
• Symptom exacerbation
following physical or cognitive
activity is a sign that the
brain’s dysfunctional
neurometabolism is being
pushed beyond tolerable limits
• In guiding recovery,
management of
neurometabolic demands on
the brain is crucial
• Do not allow patients to
exceed physiologic threshold:
Pay attention to over-exertion
- physical
- cognitive
• Concussion is most common
concussion-related symptom
• Migraine a risk factor for
concussion?
Management
• Drink adequate amounts (calculate daily maintenance) of noncaffeinated fluids daily. OK to include Gatorade, Propel or other
electrolyte-infused beverages
Maintenance Fluid requirements per body weight in kilograms
1 – 10 kg
100 mL/kg
11 - 20 kg
1000 mL + 50 mL/kg for each kg >
10 kg
> 20 kg
1500mL+ 20 mL/kg for each kg > 20
kg
• Eat 4 to 5 small, frequent meals including green, leafy vegetables (rich
in vitamin B2 and coenzyme Q10)
• Maintain regular sleep cycle of at least 8 (may need 10)
hours per
night
• Avoid physical and cognitive strain. NO sports
• Physical Therapy /Graduated Return to Play guidelines once patient is
symptom free for at least 24 to 48 hours
Management (continued)
• Abortive Medications
1. NSAIDS (ibuprofen, naproxen, etodolac, ketorolac)
2. Antiemetics including Phenergan, Zofran, Compazine or Reglan
3. Triptans (Axert, Maxalt, Zomig, Relpax, Imitrex)
4. DHE
5. Depakote
6. Dexamethasone or Medrol Pak
• Other medications that might help:
muscle relaxers (cyclobenzaprine, tizanidine)
Treatment goal: Do NOT exceed 2 to 3 doses of
analgesic medication in one week!
Other treatment strategies
• Daily Preventative Medications:
amitriptyline, topiramate (Topamax), propranolol,
gabapentin, SSRIs
• Supplementation (coenzyme Q10, riboflavin, chelated
magnesium, Omega 3s)
• Physical therapy
• Occipital nerve block injections
• Biofeedback
• Cognitive Behavioral Therapy
Other headache factors/ Setbacks
• Rebound headache
(secondary headache)
• Acute illness
• Stress, Anxiety,
Depression, ADHD
and/or behavioral
problems
• Repeat injury
• Any other chronic
disease process
Points to take home
• Education
1. Call our office if
headaches worsen or
new neurological
signs develop
2. Anticipatory
guidance
3. Watch “Head
Games” documentary
References and Resources
• Winner, P., Lewis, D. “Young Adult and Pediatric Headache Management”,
Hamilton, Ontario; 2005: page 1-232.
• www.achenet.org
• www.americanheadachesociety.org
• Finkel, A., Guskiewicz, K., Dodick, D., and Conidi, F. Sports Concussion/Mild
Traumatic Brain Injury and Headache. American Headache Society Scottsdale
Headache Symposium, November 10, 2011
• Neal, M., Wilson, J. Wesley, H. and Powers, A. Surg Neurol Int 2012; 3:16
• Lau et al. Clin J Sport Med 2009;19: 216-221
• Register-Mihalik et al. Clin J Sport Med 2007; 17: 282-288
• Gordon et al. Br J Sports Med 2006; 40: 184-186
• Wetjen et al. J Am Coll Surg. 2010; 211: 553-7
• Halstead et al. Pediatrics. 2013; 132 (5): 948-57