Pediatric Neurology Quick Talks Headache Michael Babcock Summer 2013

Scenario 7 yo boy Headaches for 4 months Headaches last 90 minutes Grabs the front of his head when it hurts Has about 1 headache a week, vomits with some of the headaches Continues to do well in school, no vision complaints

Causes of headache Primary –Migraine –Tension-type –Cluster –Paroxysmal hemicrania –SUNCT –Trigeminal neuralgia (not common in kids) –Chronic daily headache Secondary –Medication overuse (rebound) –head/neck trauma –Vascular disorder – SAH, AVM, vasculitis, CSVT –High ICP / Low ICP –Tumor –Infection CNS Other infections

History Headache – quality, severity, location, laterality, onset, time course – episodic and similar or progressive/changing Associated symptoms – systemic symptoms, fever, personality changes, seizures Preceding symptoms – aura, gradual/rapid onset Exacerbating features – migraines worse with activity; worse with laying or nocturnal or with cough/straining – signs of elevated ICP; worse with standing – signs of low ICP. Medical history – NF1, Sturge-weber, connective tissue disorder, Sickle cell, immunocompromised.

Exam Vitals – fever, ICP signs Good neurologic exam –? Altered mental status –Abnormal eye movements –Visual field testing –Fundoscopic exam –Focal weakness –UMN signs –Abnormal gait

Papilledema (normal to severe)

Work-up Imaging –Trauma –Associated seizures –AMS –Abnormal neurologic exam –Historical features – thunderclap headache, persistently lateralized, progressive course, shunt, change in pattern/type, occipital headache –Signs of elevated ICP –Considerations: no family history of migraine < 1 month of headache Young age of onset –Prior to LP CSF analysis –Pseudotumor (IIH) Accurate recording of pressure, in lateral decub position must extend LE's. –Meningitis Meningismus Fever New seizures AMS immunocompromised –SAH Thunderclap headache

Migraine Affects 7% of all children Causes $1-17 billion in lost productivity Accounts for 10 million physician visits/year in U.S.

Migraine Classification Pediatric migraine with aura –At least 2 attacks fulfilling B. –At least 3 of the following One or more fully reversible aura symptom indicating focal cortical and/or brainstem dysfunction at least 1 aura developing gradually over > 4 min or > 2 aura symptoms occurring in succession No auras lasting > 60 minutes Headache no more than 60 minutes after aura

Migraine treatment – Life-style modification Sleep – don't vary by more than one hour on school/weekend nights Exercise – regular exercise, but over-exercise can cause headache Mealtimes – 3 meals daily, don't skip meals Hydration – carry water bottle – school excuse to carry and go to bathroom Stress – stress reduction techniques Caffeine – moderation or stop Analgesic overuse –Don't use OTC pain relievers more than two-three times weekly –Opiates can also cause this –To relieve headache – have to break cycle, stop medication, headache worse for 2-3 weeks, then better.

Migraine Medications - Preventative Cyproheptadine – AAN PP – insufficient evidence – histamine and serotonin antagonist with Ca-channel blocking properties; SE – weight- gain and sedation. Can be OK for younger, non-overweight children. Beta-blockers – conflicting evidence. SE – asthma, DM, orthostatic hypotension, depression, not good for athletes Amitryptaline (TCA's) – depressino/affective disorder often co-morbid with migraines. SE – QT prolongation – get EKG, behavior change Ca-channel blockers – Verapamil – good for hemiplegic migraine AED's –Topamax – SE – weight loss, cognitive change, sedation –Depakote – SE – weight gain, PCOS, teratogenic; need CBC/LFT monitoring –Keppra – consider because low SE profile –Gabapentin – SE – sedation

Migraine Medications – Abortive Naproxen (Aleve) – 10-20mg/kg/d div Q8H. For patients over 30kg. Can give 1-2 tabs at onset, 1 more tab in 8 hours. Motrin Fioricet (acetaminophen/butalbital/caffeine) or fiorinal – good for rescue but risk of dependance, overuse – probably best not to give outside ED. Anti-emetics – Phenergan, Reglan, Compazine – can give benadryl to help with sleep/extrapyramidal effects Triptans – Sumatriptan (PO, SC, IN) – Adult oral PO dose is mg at onset, max 200mg/day PO. No dosage recommendations for children in packet. SE-- heart – vasospasm, MI, arrhythmias, HTN, stroke, seizure, rebound headaches; chest/jaw/neck pain. Ergots – nasal DHE (Migrinal nasal spray) – 1 squirt in each nostril – SE—chest pain, nausea, cannot use within 24 hours of triptan In ED – hydration with NS, Magnesium, Depakote, Ketorolac if not medication overuse, compazine, benadryl, steroid

References AAN Practice parameter – migraines Maria, B Current management in child neurology. People's medical publishing house.