Childhood HeadacheRachel Howells

Learning Outcomes

By the end of this session, you should be able to

Differentiate primary from secondary headache

Recognise and manage common primary headaches

Epidemiology

Preschool1/3 will have had a headacheMigraine headache 0-7% of population

Schoolchildren70% have ≥ 1 headache a yearPeak at 90% at age 12-13Prevalence of recurrent headache 20-30%

Case 1

Case 1

15 year old girl

Frontal headache, down neck and shoulders

2 monthsStart as soon as she rises from bed, and

relieved by lying downMissing school for 6 weeks

Primary or Secondary?

Case 1

Further historySpinal surgery 3 months ago Epidural anaesthesia

Examination Normal

Low pressure headache

Possible dural tap

ManagementEncourage mobilising Many spontaneously resolve within 3-4

monthsShort-term: CaffeineLong-term: Epidural blood patch

Primary vs Secondary Headache

Primary vs Secondary Headache

10% of headaches seen in a specialist neurology / headache clinic are secondary in origin

Population prevalence of organic disease is likely to be lower

Secondary Headache Types

Altered Intracranial PressureRaised ICPLow Pressure Headaches

VascularSubarachnoid Headache (eg AVM)DissectionVasculitisDrugs

Drug effectAnalgesia induced headache

Central (thalamic) painTrigeminal neuralgiaCluster headaches

LocalDental AbscessSinusitisPost head injury

How to identify a secondary headache

How to identify a secondary headache

Brain Imaging

Examination

History

Indications that a headache is secondary to altered intracranial pressure

Indications

1. Timing of headache

2. Postural manoeuvres

3. Associated symptoms

Timing of Headache

Morning but from sleep, before rising

Raised Intracranial Pressure

Morning but after getting up

Low Pressure Headache

Postural Manoeuvres

Getting up relieves headache

Coughing and straining exacerbates it

Raised Intracranial Pressure

Lying down relieves headache

Low Pressure Headache or

Sinusitis

Associated Symptoms

Frontal headache

Associations Morning vomitingOther neurology

Confusion

Raised Intracranial Pressure

Frontal headache

AssociationsPain / parasthesiae across shoulders*

Blocked nose, facial pain¤

Low Pressure Headache* or

Sinusitis¤

Case 2

Case 2

16 year old girl seen in OPD

Frontal headache There when she wakes, gets better when

she gets upNo nausea or other neurological

symptoms

4 months, not getting any worse

Primary or Secondary?Is this raised or low intracranial pressure?

Case 2 continued

Past History – nil

Examination Enlarged blind spots on confrontationNo other alteration of visual fieldsPapilloedema

No ataxia, long tract signs

What diagnoses need to be considered?

Causes of Raised Intracranial Pressure

HydrocephalusTumour obstructing CSF pathways Obstruction to CSF re-absorption (post haemorrhage or meningitis)Congenital (eg aqueduct stenosis)

Cerebral oedemaInflammation (ADEM, stroke)Infection (meningitis etc)CO2 retention (obstructive sleep apnoea)Metabolic (DKA, other)

Idiopathic (Benign)Intracranial Hypertension

Idiopathic Intracranial Hypertension

Aetiology unknownAdolescent girlsObesity, drugs, steroid withdrawalVisual loss (10%) may be permanent and

is only indication for treatment

Raised intracranial pressure in the absence of space occupying lesion

or obstruction to CSF flow

Indications

1. Timing of headache

2. Postural manoeuvres

3. Associated symptoms

Case 3

Case 3

14 year old girlHeadache since the evening beforeSingle and worst headache everSudden onset

Vomited once at start

No history of head injury / prodrome

Case 3

ExaminationAfebrileNo meningismGCS 15

Unilateral facial weakness with frontal sparing

Ipsilateral arm weakness with hyporeflexia

What diagnoses should you entertain?

CT brain

Case 3

CT shows haemorrhage around area of left basal ganglia

Patient admits to using some cocaine at a party with her 18 year-old sister

More information to help you identify secondary

headache

History

Timecourse

Single or first severe headache

Recurrent severe headachesOne a month

2 years without progression

Headaches all day on most days

18 months

Headaches every few monthsthen weeksthen days

Now every day

Severe headaches all day for 12 days2 months ago

None since

Bleed?

Bleed?

Tumour?

TTH?

Migraine?

Timecourse

Single or first severe headache

Recurrent severe headachesOne a month

2 years without progression

Headaches all day on most days

18 months

Headaches every few monthsthen weeksthen days

Now every day

Severe headaches all day for 12 days2 months ago

None since

Pointers in History: Summary

1. Timing of Headache

2. Postural manoeuvres

3. Symptoms associated with headache

4. Timecourse

Examination

Purpose of Examination

To support your clinical impression made on history

To rule out other differentialsTo adhere to many families expectations

to be taken seriouslyto be able to support your view that nothing serious

is going on

Essential elements of Examination

VisionAcuityFields including blind spotExtraocular movementsLong tract signs

TonePower Reflexes

Cerebellar signsFinger-nose test (eyes shut)TremorDysarthriaGait

Blood pressure

Bruit

Conscious level

Fundi

Case 4

Case 4

8 year old boy with 10 month history of Bi-temporal headacheThrobbingWorse with movement / exerciseMother says looks pale and unwell

Usually start in morningLast all day

Case 4

No family history

Examination is normal

Primary or Secondary?

What is the most likely diagnosis?

Migraine without aura

What causes migraine?

Migraine headache Nerve efferents – trigeminal,

vagal Meninges have pain fibres with

inputs from trigeminal complex Vasodilation of meningeal

vessels

Michael Creighton

Why do some people get migraine headaches?

Genetic

Abnormal inhibitory inputs to trigeminal nerve complex

Clinical Implications

Abnormal inhibition to nociceptive parts of brain

Abnormal response to changes in environment eg sleep, diet, smells

Pain is exacerbated by noise and light

Headache relieved by sleep in a dark room

Migraine symptoms Pain involves the face

(trigeminal) Throbbing pain (meningeal) Pallor and nausea (vagal)

Delia Malchert

Migraine

ClassificationMigraine without aura (commonest)Migraine with aura

Basilar migraineOphthalmoplegic migraineAlternating hemiplegia

Migraine

The diagnosis is a clinical one

Families can be reassured byFamily historyLongevity of symptomsNormal examinationAddressing their underlying concerns

Management

1. Explanation

This is not a tumour Worst in second decade of life Most patients will get fewer headaches

as they get older

Management

2. Treatment of attacks

Analgesia as soon as an attack starts Ibuprofen works best (one RCT)May be supplemented by anti-emetic

Patients over 12 may respond to im, oral or nasal sanomigran (Imigran)

Management

3. Prevention – control of environment

‘Sleep hygiene’ – regular sleep ‘Diet hygiene’ – avoid long breaks ± snack

before bed, avoid caffeine, low amine diet ‘Exercise hygiene’ – regular exercise,

maintain hydrationAvoid stress – relaxation training, CBT

Management

4. Prevention – pharmacological

No magic bullet, trial basis onlyPizotifenPropanolol

Feverfew

Case 5

Case 5

10 year-old girl with 18 month history ofBilateral headache, mainly vertexConstantComes on during day Not worsened by walkingNo aura or pallor / nausea

5/7 days a week, most weeks of the year

Case 5

No family historyExamination normal

Local grammar schoolPredicted for A grades in 10 GSCEs No external sources of anxiety – stable

home, not being bulliedTrying to keep going to school

Case 5

Alternating ibuprofen 400mg and co-codamol for headaches

‘Nothing really works’

Primary or secondary?

What is the most likely diagnosis?

Chronic Tension-Type Headache

How is the diagnosis made?

CTTH

No features suggestive of organic diseaseTime of dayPostural manoeuvresAssociated symptoms Time course

Not classifiable as migraineExamination normal

Management

Explanation

Although not an organic disease, effects on life can be significant (school etc)

Treat attacks Simple analgesia Avoid multiple drugs Feverfew / Levomenthol / TigerBalm

Management

Prevention of attacks

Sleep, diet, exercise hygieneAddress anxiety (relaxation training, CBT)Maintain contact with school, try and

attend but manage workload

What did you learn?

You should now be able to

Differentiate primary from secondary headache

Recognise and manage common primary headaches

Migraine with / without auraTension-type headache

Any questions?

Thank you for listening

Rachel Howells