Headache in Children

Pain-sensitive structures in the head Intracranial Structures Venous sinuses and afferent veins Arteries of the dura mater and pia-arachnoid Arteries of the base of the brain and their major branches Parts of the dura matter near the large vessels

Pain-sensitive structures in the head Extracranial Structures Skin Subcutaneous tissue Muscles Periosteum of the skull Mucosa Extracranial arteries Delicate structures of the eye, ear, nasal cavities and sinuses

Pain-sensitive structures in the head Nerves Trigeminal Facial Glossopharyngeal Vagus Upper three cervical roots

Pathophysiology of headache: Pain insensitive structures Skull Pia-arachnoid and dura over the convexity of the brain Brain parenchyma Ependyma Choroid plexuses

Pain Mechanisms Traction On the Circle of Willis and dural structures Inflammation Of intra- and extracranial structures Of the meninges, and blood vessels Vascular distention and spasm Of intra- and extracranial vessels

Pain Mechanisms Muscle contraction Of neck and scalp muscles Pressure - changes in ICP - Within nasal or paranasal cavities, orbits, ears and teeth, and on nerve-containing fibers

Temporal profile of headache AcuteAcute Recurrent Chronic progressive Chronic nonprogressive Time (days)

Migraine most important and frequent type of headache in the pediatric population Prevalence Girls - adolescents Boys - younger than 10 yr 50 % spontaneous prolonged remission after the 10th birthday Adults, 5–10% of men and 15–20% of women have migraine headaches

Migraine without aura the most prevalent type of migraine in children headache is throbbing or pounding and tends to be unilateral at onset or throughout its duration but may also be located in the bifrontal or temporal regions It may not be hemicranial in children and is less intense compared with the migraine in adults

Migraine without aura headache usually persists for 1–3 hr although the pain may last for as long as 72 hr pain may inhibit daily activity, because physical activity aggravates the pain characteristic feature intense nausea and vomiting

Migraine without aura Additional symptoms extreme paleness, photophobia, light- headedness, phonophobia, osmophobia (aversion to odors), and paresthesias of the hands and feet positive family history on the maternal side in ≈90% of children with migraine without aura

Migraine without aura Additional features near synchrony with perimenstrual or periovulation timing gradual appearance after sustained exercise relief with sleep stereotypical prodromes (hypersomnia, food craving, irritability, moodiness) precipitation by food or odors onset after a letdown or high period of stress

Diagnostic Criteria Migraine without aura A At least five attacks B Headache attack lasts 1–72 hr (untreated or unsuccessfully treated) C Headache has at least two of the following characteristics: Unilateral location, may be bilateral Pulsating quality Moderate or severe intensity Aggravation by or avoidance of routine physical activity (i.e., walking or climbing stairs) D During headache at least one of the following: Nausea, vomiting, or both Photophobia and Phonophobia E Not attributed to another disorder

Migraine with aura Aura precedes the headache Visual aura are uncommon in children but when they occur they may be in the form of Binocular visual impairment with scotoma (77%) Distortion or hallucinations (16%) Monocular visual impairment or scotoma (7%) [hachinshi et al., 1973]

Migraine with aura Vertigo and light headedness Sensory symptoms Perioral paresthesias Numbness of the hands and feet Distortion of body image (alice in wonderland)

DIAGNOSTIC CRITERIA WITH AURA (CLASSIC MIGRAINE) A At least two attacks B Migraine aura fulfills criteria for typical aura, hemiplegic aura, or basilar-type aura C Not attributed to another disorder

DIAGNOSTIC CRITERIA WITH AURA (CLASSIC MIGRAINE) TYPICAL AURA 1 Fully reversible visual, sensory, or speech symptoms (or any combination) but no motor weakness 2 Homonymous or bilateral visual symptoms including positive features (e.g., flickering lights, spots, lines) or negative features (e.g., loss of vision), or unilateral sensory symptoms including positive features (e.g., visual loss, pins and needles) or negative features (i.e., numbness), or any combination

DIAGNOSTIC CRITERIA WITH AURA (CLASSIC MIGRAINE) 3 At least one of: a) At least one symptom develops gradually over a minimum of 5 min, or different symptoms occur in succession, or both b) Each symptom lasts for at least 5 min and for no longer than 60 min 4 Headache that meets criteria for migraine without aura begins during the aura or follows aura within 60 min

Hemiplegic Migraine A migraine aura Sudden onset of unilateral sensory or motor signs during the migraine episode Characterized as numbness of the face, arm, leg, unilateral weakness and aphasia May be transient or may persist for days

Hemiplegic Migraine Good prognosis (+) family history of hemiplegic migraine

Basilar-type migraine Brainstem signs predominate because of the vasoconstrictor of the basilar and posterior cerebral arteries Vertigo, tinnitus, diplopia,blurred vision, scotoma, ataxia and occipital headache Pupils may be dilated, ptosis Alteration in consciousness followed by seizures may occur

Basilar-type migraine There is complete resolution of the neurologic signs and symptoms Minor head injury can precipitate the headache M = F Girls < 4 years old of higher risk

Childhood Periodic Syndromes—Migraine Precursor Cyclic vomiting Recurrent episodic attacks, usually stereotypical in the individual, of vomiting and intense nausea. Attacks are associated w/ lethargy and pallor There is complete resolution of symptoms between attacks International Classification of Headache Disorders Criteria for Cyclic Vomiting

Periodic Syndromes—Migraine Precursor Cyclic vomiting Diagnostic Criteria: A. At least five attacks fulfilling criteria B and C B. Episodic attacks, stereotypical in the individual patient of intense nausea and vomiting lasting 1-5 days C. Vomiting during attacks occurs at least 5 times/ hour for at least 1 hour D. Symptom-free between attacks E. Not attributed to another disorder. History and Physical Examination do not reveal signs of gastrointestinal disease.

Childhood Periodic Syndromes—Migraine Precursor Cyclic vomiting Treatment rectally administered or injected antiemetics such as dimenhydrinate or ondansetron careful attention to fluid replacement if the vomiting is excessive

Precursors of migraine Abdominal migraine Description: An idiopathic recurrent disorder seem mainly in children & characterized by episodic midline abdominal pain manifesting in attacks lasting 1-72 hours with normality between episodes. The pain is of moderate-to-severe intensity & associated with vasomotor symptoms, nausea and vomiting.

Precursors of migraine Abdominal migraine Diagnostic Criteria: A. At least 5 attacks fulfilling criteria B through D B. Attacks of abdominal pain lasting 1-72 hours C. Abdominal pain has all of the ff. characteristics A. Midline location, periumbilical or poorly localized B. Dull or “just sore” quality C. Moderate or severe intensity D. During abdominal pain, at least two of the ff: A. Anorexia B. Nausea C. Vomiting D. Pallor

Management of Pediatric Migraine Goals of Treatment 1. Reduction of headache frequency, severity, duration, and disability 2. Reduction of reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapies 3. Improvement in quality of life 4. Avoidance of acute headache medication escalation 5. Education and enabling of patients to manage their disease to enhance personal control of their migraine 6. Reduction of headache-related distress and psychological symptoms

Treatment of Pediatric Migraine Acute attack Analgesic 1. acetaminophen (15 mg/kg) 2. ibuprofen (7.5–10 mg/kg) Antiemetic 1. dimenhydrinate by rectal suppository 5 mg/kg/24 hr in four divided doses 2. Parenteral metoclopramide

Treatment of Pediatric Migraine Acute attack Triptans (e.g., Sumatriptan) are specific and selective 5-hydroxytryptamine receptor agonists that are effective abortive drugs Sumatriptan may be administered subcutaneously, nasally, or orally suggested dose is 5 mg in children <25 kg, 10 mg (two sprays) in those weighing 25–50 kg, and 20 mg sumatriptan in children ≥50 kg

Treatment Acute attack Triptans (e.g., Sumatriptan) dose may be repeated 2 or more hours after the initial dose, limited to two doses per 24 hr adverse effects are usually minor and transient, and include hot flushes, nausea and vomiting, fatigue, and drowsiness

Children may develop severe intractable migraine attacks or status migrainosus (persistent headache lasting longer than 3 days) that are unresponsive to conventional drug regimens Intravenous prochlorperazine, 0.15 mg/kg (max 10 mg)

continuous daily medication (prophylactic therapy) severity and frequency of the headaches on the impact of the migraine on the child's daily activities, including school attendance and performance as well as participation in recreation if a child experiences more than two to four severe episodes monthly or is unable to attend school regularly

continuous daily medication (prophylactic therapy) Ppropranolol 10–20 mg tid (beginning with 10 mg/24 hr and gradually increasing the drug to the maximum dose or until the desired therapeutic effect is achieved) in children 7– 8 yr and older. A common mistake is to discontinue the drug prematurely, because it often takes several weeks to a month until the drug is effective.

continuous daily medication (prophylactic therapy) Flunarizine initial dose is 5 mg at bedtime and increased if necessary to 10 mg most frequent side effect is drowsiness

Behavioral Management effective method for the treatment of migraine in some children and adolescents Biofeedback can be mastered by most children older than 8 yr and has been effective in many clinical trials

Indications for Neuroimaging in a Child with Headaches Abnormal neurologic sign Recent school failure, behavioral change, fall-off in linear growth rate Headache awakens child during sleep; early morning headache, with increase in frequency and severity Periodic headaches and seizures coincide, especially if seizure has a focal onset

Indications for Neuroimaging in a Child with Headaches Migraine and seizure occur in the same episode, and vascular symptoms precede the seizure (20–50% risk of tumor or arteriovenous malformation) Cluster headaches in child; any child <5–6 yr whose principal complaint is a headache Focal neurologic symptoms or signs developing during a headache (i.e., complicated migraine)

Indications for Neuroimaging in a Child with Headaches Focal neurologic symptoms or signs (except classic visual symptoms of migraine) develop during the aura, with fixed laterality; focal signs of the aura persisting or recurring in the headache phase Visual graying-out occurring at the peak of a headache instead of the aura Brief cough headache in a child or adolescent