Welcome Applicants!

Morning Report: Thursday, December 8th

The Head CT…

The MRI…

HeadachesWhen to reassure and when to worry…

Question #1

A 12 yo female presents to the ED with a 1 ½ day h/o severe, throbbing right-sided frontemporal head pain. It necessitated her staying home from school today. She has had similar HAs in the past. She also c/o associated nausea, vomiting and sensitivity to light. Sleeping helps but has not gotten rid of this HA.

Question #2

An 11 yo male presents to the ED with recent onset of an extreme, nonthrobbing, deep pain in and around his right eye. He has also started to notice that the pain is spreading to the right side of his face. There has been no h/o trauma to that eye or side of the face. Mom says that his face appears more flushed than usual, and his right eye appears swollen and watery.

Question #3

A 9 yo female presents to her PCP with a month h/o recurrent HAs. She says it feels like there is a “tight rubber band” around her head. Mom has received a phone call from the school almost daily around 2pm regarding these HAs. Ibuprofen and rest seem to relieve the HAs. Mom is concerned that she has missed so many afternoons of school, which may affect her ability to get into Harvard.

Question #4

A 13 yo female with h/o migraines presents to the PCP with c/o increasing HA frequency. She reports that the location and severity have not changed. Instead of getting headaches once every 2 weeks, however, she is currently getting them daily. She was initially taking 200mg of Ibuprofen every 4-6h for her HAs, but that did not provide her with sufficient relief. She then switched to Excedrin Migraine and currently takes 2 pills about every 8 hours.

Question #5

A 5 yo male presents to the ED with a three week h/o HA. It started after a minor fall on the playground and has gotten worse despite attempts to treat with both Tylenol and Ibuprofen. Mom also comments on his “unluckiness,” as he recently acquired a GI illness which has caused him to vomit frequently and not sleep well. Today, she had difficulty waking him from his nap, so she brought him to be evaluated.

Question #1

A 12 yo female presents to the ED with a 1 ½ day h/o severe, throbbing right-sided frontemporal head pain. It necessitated her staying home from school today. She has had similar HAs in the past. She also c/o associated nausea, vomiting and sensitivity to light. Sleeping helps but has not gotten rid of this HA.

*Migraine

Evaluation

No support for routine laboratory studies or LP

Routine EEG not recommended

Role of neuroimaging

NOT indicated in children with recurrent HAs and a normal neuro exam

Should be considered:

Recent onset of severe HA

Change in type of HA

Neurologic dysfunction

Should be done with an abnormal neurologic exam or with coexistence of seizures

Management

First step: appreciate the degree of disability

Treatment regimen must balance biobehavioral strategies with pharmocologic measures

Acute treatments are the mainstay of migraine management!

1. Take the medication as soon as possible

2. Take the appropriate dose

3. Have the medication available at the location where the patient usually has the HAs

4. Avoid analgesic overuse (>3-5 doses/ week)

**Use should be limited to patients whose HAs occur with sufficient frequency (@ least 3/mo) or severity to warrant daily treatment**

Question #2

An 11 yo male presents to the ED with recent onset of an extreme, nonthrobbing, deep pain in and around his right eye. He has also started to notice that the pain is spreading to the right side of his face. There has been no h/o trauma to that eye or side of the face. Mom says that his face appears more flushed than usual, and his right eye appears swollen and watery.

Cluster Headache

Rare in children <10yo

90% of sufferers are male

Extreme nonthrobbing deep pain in and around one eye that spreads onto the face on the affected side

Bursts of pain last 60-90 mins and repeat 2-6 times per day for several weeks, then vanish for a period of months to years

Accompanying facial flushing and eye swelling/ watering

Cluster Headache

Treatments Acute attacks

Sumatriptans

100% O2 @8-10 lpm

Prophylaxis Methysergide

Lithium

Corticosteroids

Question #3

A 9 yo female presents to her PCP with a month h/o recurrent HAs. She says it feels like there is a “tight rubber band” around her head. Mom has received a phone call from the school almost daily around 2pm regarding these HAs. Ibuprofen and rest seem to relieve the HAs. Mom is concerned that she has missed so many afternoons of school, which may affect her ability to get into Harvard.

*Stress or Tension Headache

Diffuse, symmetrically distributed, throbbing pain around the head (“band like”)

Usually present most of the time, but there may be symptom-free periods

Fatigue is a common feature

Nearly all children who have daily HAs where an organic cause has been eliminated, underlying social or emotional difficulties can be found

*Stress or Tension Headache

Treatment Acute

Identify the predisposing, precipitating and perpetuating factors in the child’s home or school…and avoid them (if possible)!

Rest

Analgesia

Chronic Relaxation techniques

Massage therapy

Acupuncture

Amitryptiline

Question #4

A 13 yo female with h/o migraines presents to the PCP with c/o increasing HA frequency. She reports that the location and severity have not changed. Instead of getting headaches once every 2 weeks, however, she is currently getting them daily. She was initially taking 200mg of Ibuprofen every 4-6h for her HAs, but that did not provide her with sufficient relief. She then switched to Excedrin Migraine and currently takes 2 pills about every 8 hours.

*Medication Overuse Headache

Can occur with opiates, ergotamines, NSAIDs, or acetaminophen

Treatment includes tapering off acute symptomatic treatment (and educating the patient!)

Limit PRNs to one dose/day and 3 doses per week

Consider prophylactic treatment

Emphasize the importance of diet, exercise and sleep

Question #5

A 5 yo male presents to the ED with a three week h/o HA. It started after a minor fall on the playground and has gotten worse despite attempts to treat with both Tylenol and Ibuprofen. Mom also comments on his “unluckiness,” as he recently acquired a GI illness which has caused him to vomit frequently and not sleep well. Today, she had difficulty waking him from his nap, so she brought him to be evaluated.

Headache Due to Increased ICP

Time to worry!!!

Causes

Meningitis/ encephalitis

Diabetic ketoacidosis

Mass lesion Tumor

Hemorrhage

Hydrocephalus Tumor

Congenital malformation

Hypoxic-Ischemic encephalopathy

Pseudotumor cerebri

Concerning Historical Features

Chronic and PROGRESSIVE HA without pain-free intervals

HA worse at night or immediately after waking

HA worse during maneuvers that increase venous pressure

Bending over

Coughing

Sneezing

Straining to stool

Concerning Historical Features

Repetitive vomiting (especially early AM)

Focal neurologic signs or symptoms Visual disturbances

Paraesthesias

Weakness

Ataxia

Signs and Symptoms

Infants

Widened sutures

Bulging fontanelle

Persistent downward eye deviation (“sunsetting”)

Increased head circumference

Toddler/ School-age Children

Lethargy or irritability

HA

Vomiting

Papilledema

Diplopia/ enlarged blind spot

Abducens palsy

Mild ataxia

Cushing’s Triad1. Alterations

in respirations or apnea

2. HTN3. Bradycardi

a

*Management

ABCs!!!

BRIEF neurologic exam with assignment of GCS HOB at 30 degrees

If life-threatening increased ICP with impending or overt signs of herniation Mannitol

Moderate hyperventilation

*Management

Imaging/ diagnostic studies CT

Allows rapid definition of surgical lesions

Sensitive to bony abnormalities

MRI Exquisite resolution of brain anatomy and

delineation of CBF

Sensitive to cerebral edema and demyelinating d/o

Superior to CT for visualization of the posterior fossa, cortical contusions, and white matter shearing lesions

*Management

Imaging/ diagnostic studies LP

Diagnostic for meningitis, encephalitis, pseudotumor cerebri

Contraindicated

Signs of increased ICP/ focal deficit

Coagulopathy

Hemodynamic instability

*Management

Isotonic IVF

Vasopressors CPP=MAP-ICP

CPP>60mmHg (>50 mmHg in infants and young kids)

ICP<15-25mmHg

Monitor serum electrolytes DI

Cerebral salt wasting

SIADH

*Management

Control agitation, fever, seizure activity

Maintain oxygenation, ventilation and hemodynamic stability to prevent secondary brain injury

Steroids Only with cerebral edema associated

with intracranial malignancy

Thanks for your attention!!Noon Conference: Guest speaker, Dr. Peters on VUR