Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

HEADACHE in Children and Adolescence An Approach to Clinical Diagnosis Dr. Anis Ali SYED Consultant Paediatrician . Headache ⚫ Half of children experience one or more episodes of headache by 7 years of age. ⚫ Most of children experience headache by 15-years of age. ⚫ 25% of Adolescents suffer from weekly headache resulting in school absence and reduction in quality of life ⚫ Headache is one of the most frequently reported illnesses in 10 – 24 age group. Headache ⚫ Headache is usually a Benign Symptom. ⚫ In Majority of patients it is self resolving and no underlying cause is detected. ⚫ Sometimes it may be a Manifestation of a serious illness like Meningitis, Brain tumour or Intracranial haemorrhage. ⚫ In Emergency settings about 5% of patients have a serious Neurological cause____where it is Imperative that a Rapid diagnosis is made. PATHO-PHYSIOLOGY of HEADACHE ? Pain in the Brain SOURCES of PAIN ⚫ The brain parenchyma, its ependymal linings are insensitive to PAIN. ⚫ All meninges except basal dura are also insensitive to pain. ⚫ Headache is due to stimulation of Pain receptors outside the brain substance. Pain Sensitive Structures of Head & Neck INTRACRANIAL STRUCTURES ⚫Cerebral and dural arteries. ⚫Large veins and venous sinuses. ⚫Dura mater at base of brain. Pain Sensitive Structures of Head & Neck EXTRACRANIAL STRUCTURES ⚫ Cranial nerves and Cervical roots. ⚫ Extracranial arteries. ⚫ Scalp and Muscles attached to Skull. ⚫ Paranasal sinuses & Middle Ear. ⚫ Periostium & Teeth Mechanism of Pain Production ⚫ Dilatation of Intra or Extra-Cranial Arteries. ⚫ Traction / Displacement of Intracranial Arteries and large veins or their dural envelope (SOL). ⚫ Compression, traction or inflammation of Cranial or Spinal Nerve roots. ⚫ Spasm, Inflammation or Trauma to Cranial or Cervical muscles. ⚫ Meningeal irritation, Raised IOP. ⚫ Inappropriate activation of Brain stem, Cranial Ns.Location of HeadacheLocation of Headache Location of Headache NERVE SUPPLY OF PAIN SENSITIVE INTRACRANIAL STRUCTURES. ⚫ SUPRATENTORIAL VESSELS Trigeminal Nerve ⚫ INFRATENTORIAL VESSELS Cervical Nerves 1, 2, 3.Location of Headache IHS Classification PRIMARY HEADACHE ⚫ Tension Type 69 % ⚫ Migraine 16 % ⚫ Idiopathic Stabbing 2 % ⚫ Cluster 0.1% ⚫ Exertional 1 % IHS Classification SECONDARY HEADACHE ⚫ Systemic Infectio63 % ⚫ Head Injury 04 % ⚫ Vascular Disorders01 % ⚫ Subarachnoid H’age < 1 % ⚫ Brain Tumour 0.1 % Approach to Diagnosis ⚫HISTORY ⚫PHYSICAL EXAMINATION ⚫INVESTIGATIONS HISTORY AGE OF ONSET ⚫ Migraine headaches begin < 10 years age ⚫ Tension Headache in Adolescent period. MODE OF ONSET ⚫ Abrupt onset of severe headache ⚫ ‘Thunderclap Headachor ⚫ ‘Worst headache of my life’ may mean ICH. HISTORY FREQUENCY OF EPISODES ⚫ Cluster Headache : 2-3 times / day for Months. ⚫ Migraine : 2-4 episodes / month. ⚫ Tension Headache : 2-7 episodes / week. HISTORY DURATION OF EPISODE ⚫ Cluster Headache : 5-15 min (may last up to 1 hour). ⚫ Migraine : 1-3 hours in young children. ( may last 48 – 72 hours in Adolescents) ⚫ Tension Type Headache : May last whole day. HISTORY TIME OF EPISODE ⚫ Lying down, Sleep, Early Morning : Intracranial Pathology ⚫ Late Morning Hours : Frontal Sinusitis ⚫ Late during Day : Tension Headache HISTORY PRECEDING EVENTS ⚫ Aura or Prodrome : Migraine. ⚫ Head Trauma QUALITY ⚫ Throbbing / Pulsating / Hammering – Migraine. ⚫ Squeezing ---- Tension ⚫ Aching / Deep continuous ---- Cluster. HISTORY LOCATION Localized Headaches -- suggest secondary (Sinusitis, OM, Dental). Bi-Frontal or Bi-temporal - Migraine Retro-orbital or Temporal -- Cluster. Occipital Headaches: – Posteroir Cranial Fossa Pathology -- Basilar Migraine HISTORY TRIGERRING FACTORS ⚫ Posture, Activity, Lack of sleep, Exertion, Foods, ⚫ Bright lights, Noise, Menstrual Period. RELIEVING FACTORS ⚫ Rest and sleep in dark room ( Migraine), ⚫ Sleep ( Tension), Analgesia, Medications, Oxygen. HISTORY RELATIONSHIP WITH OTHER ACTIVITY ⚫ School problems, change of School or home, ⚫ Recent changes in sleep, Exercise or Diet. RECENT CHANGES IN GROWTH, VISION ⚫ Pituitary tumours ⚫ Craniopharyngioma, ⚫ BICH. HISTORY ASSOCIATED SYMPTOMS ⚫ Fever, Neck Pain, Pallor, Vomiting, Diplopia, Dizziness PSYCHO- SCOIAL PROBLEMS ⚫ Tension Headache FAMILY HISTORY ⚫ Migraine. Details of Typical Episode ⚫ ? Preceding events , trauma, any Aura such as Visual changes or Paraesthesia, time of the day, location, unilateral or bilateral. ⚫ Nature and Progression of pain e.g., dull, throbbing or banging and duration of an episode. ⚫ Severity --- how much disruption it causes in every day activity or lost school days. Details of Typical Episode ⚫ Exacerbating or Relieving factors. ⚫ Associated symptoms like vomiting, photophobia or phono-phobia, pallor and Sick looking, weakness, speech or visual changes or other Neurological symptoms. ⚫ Trigger factors like stress and exercise, head trauma, premenstrual period or use of pill. ⚫ Any other chronic illness ( Sickle cell disease, Immune deficincy, Coagulation disorder, Cardica disease, NF1, TS. PHYSICAL EXAMINATION A thorough Physical Examination is very desirable : ⚫ General Appearance, Skin Examination. ⚫ Vital Signs (Hypertension). ⚫ Growth parameters including Head circumference. ⚫ Examination of Eye, ENT, Teeth, TMJ & Spine. ⚫ Palpation / Auscultation of Head & Neck and Eyes. ⚫ Complete Neurological Examination including Fundoscopy and check for signs of meningeal irritation. ? CLINICAL TYPE OF HEADACHE HEADACHE CLINICAL CLASSIFICATION ⚫Acute / New-onset Headache ⚫Acute Recurrent Headache ⚫Chronic Non-progressive Headache ⚫Chronic and Progressive Headache Acute Headache ⚫ Systemic infection ⚫ Intracranial infection (meningitis, encephalitis) ⚫ Trauma ⚫ ICH ⚫ Hypertension ⚫ Sinusitis, Otitis media ⚫ Dental abscess ⚫ Eyes problems ⚫ Toxins ( CO, Drugs ) Acute Recurrent Headache ⚫ Migraine ⚫ Cluster headache ⚫ Seizure headache Clinical Types of Migraine ⚫ Migraine with Aura (Classic Migraine). ⚫ Migraine with out Aura (Common Migraine) ⚫ Migraine-Equivalent Syndromes ⚫ (Associated with Transitory Neurological Dysfunction) ⚫ Acute Confusional Migraine ⚫ Basilar Migraine / Benign Paroxysmal Vertigo ⚫ Cyclical Vomiting ⚫ Hemiplegic & Opthalmoplegic Migraine ⚫ Transient Global Amnesia ⚫ Paroxysmal Torticollis IHS Diagnostic Criteria of Paediatric Migraine without Aura Five or more episodes of headache lasting 1-72 hours separated by symptom free intervals , And at least two of the following features: ⚫ Unilateral or Bilateral pain. ⚫ Pain of throbbing nature. ⚫ Moderate or Severe Pain aggravated by Routine Activity. Associated with at least one of the following : ⚫ Nausea / Vomiting ⚫ Photophobia / Phonophobia. Cluster Headache Clusters of Headaches recur over periods of weeks or months separated by intervals of 1-2 years. ⚫ Onset after 10 years of age, ↑ males, F.H. –ve. ⚫ Headache often begins during sleep, occur in bursts lasting 15-60 minutes and repeats 2-6/day. ⚫ Usually starts behind and around the eyes then becomes Hemi-cranial and always recur on same side of head in subsequent attacks. ⚫ During the attack person cannot stay Still and prefers to walk around in agony Cluster Headache (contd....) ⚫ Nausea / Vomiting do not occur . ⚫ Scalp may be tender or oedematous. ⚫ Ipsilateral Hemicranial Autonomic Dysfunction. ⚫ No much relief from common analgesics. ⚫ Sumatriptan ( s/c or nasal spray ) and Oxygen Inhalation can treat Acute attack. ⚫ Recurrence can be prevented by Prednisolone.Chronic Non-progressive Headache ⚫ Tension headache ⚫ Post-traumatic headache ⚫ Analgesic rebound headache ⚫ Caffeine headache ⚫ Substance abuse IHS Criteria For Tension -Type Headache At Least 10 episodes lasting 30 min to 7 days with At least two of the following : ⚫ Pressing / tightening quality ⚫ Bilateral location ⚫ Mild or Moderate Pain. ⚫ Pain not aggravated by routine physical activity. And None of the following ⚫ Nausea or Vomiting ⚫ Photophobia / Phonophobia or one but not both.Chronic Progressive Headache ⚫Brain tumours ⚫Brain abscess ⚫Benign Intracranial Hypertension ⚫Hydrocephalus ⚫Cerebral vascular malformations Clinical Features Indicating Intracranial Pathology Patient History ⚫ Headache awakening the child from sleep. ⚫ Early morning Headache upon awakening. ⚫ Headache worsened in lying down posture, cough, micturition, defecation or exertion. ⚫ Change in pattern or severity of Headache. ⚫ Occipital Headache Clinical Features Indicating Intracranial Pathology ⚫ Age < 6 years ⚫ Personality change / Developmental Regression / Poor school performances. ⚫ Abnormal Growth, Pubertal Development. ⚫ Headache duration less than 6 months. ⚫ Absence of Family history of Migraine. Clinical Features Indicating Intracranial Pathology Co-existing Medical Conditions ⚫ Immune deficiency ⚫ Coagulopathy. ⚫ Congenital Heart Diseases, R to L shunts. ⚫ Sickle cell disease, Polycythaemia ⚫ Malignancy or Past History of Malignancy. Clinical Features Indicating Intracranial Pathology PHYSICAL EXAMINATION. ⚫ Abnormal Neurological Examination like Ataxia, weakness, Focal signs. ⚫ Diplopia, abnormal eye movements, Papilloedema, Retinal haemorrhages. ⚫ Cranial bruits. ⚫ Neurocutaneous syndromes. Miscellaneous Headaches ⚫ Connective tissue disorders ⚫ Metabolic disorders. ⚫ Hypoxia / hypercapnoea ⚫ Dialysis ⚫ Procedures : LP, Intrathecal injections ⚫ Neuralgias. INVESTIGATIONS ⚫FBC ⚫U & E ⚫LFT ⚫CRP ⚫Blood & MSU Culture. ⚫Autoimmune Screen, Serology. INVESTGATIONS INDICATIONS OF URGENT NEUROIMAGING ⚫ ‘Worst’ Headache of life / Thunder Clasp Headache ⚫ Sudden onset of new severe headache. ⚫ Headache increasing in severity/frequency. ⚫ Recurrent early morning headaches ⚫ Frequent Awakening due to headaches. ⚫ Occipital Headache ⚫ Increase pain with straining, coughing. ⚫ Abnormal Neurological Examination. ⚫ Reduced visual acuity. ⚫ Change in Growth Rate ⚫ Developmental Regression. ⚫ Recent behavioural change. MANAGEMENT ⚫Secondary Headache ⚫Primary Headache SECONDARY HEADACHE ⚫Treatment of underlying Cause if possible. PRIMARY HEADACHE Pharmacological Therapy ⚫ Abortive Therapy. ⚫ Prophylactic Therapy. Psychological Support. Pain management techniques. Behavioural therapies. Abortive Therapy GENERAL MEASURES ❑ Education of child and family how to deal with an acute attack. ❑ Keeping a diary of attacks. ❑ Precipitating Factors should be identified like stress, poor sleep, specific foods, weather changes, Menstrual period. ❑ Resting in Dark Quiet Room with a cool cloth applied to Head are quite helpful. Abortive Therapy MEDICATION Analgesics : Paracetamol, Ibuprofen 5HT 1Receptor Agonists:(Not indicated in Complicated Migraine). Sumatriptan, Zolmitripton Anti-emetics : Prochlorperazine, Metchlopramide, Domperidone Prophylaxis of Migraine INDICATION 1. At least 2 or more attacks / month. 2. Increasing Frequency of attacks. 3. Significant Disability despite adequate treatment during each attack. 4. Cannot tolerate suitable treatment for acute attack. DRUGS Propranolol, Pizotifen, TopiramateTHANKS.