Approach to a child/adolescent with a headache

Overview, common causes, red flags and approach to a children presenting with a headache

1. HEADACHE IN CHILDREN

2. OVERVIEW Classification Common causes Approach Red flags Evaluation Treatment

3. It is referred as pain over forehead, orbit, temples, or scalp and does not include isolated facial and neck pain. Headache is a common complaint in children and adolescents. 75% of children have reported significant headache by the time they are 15 years of age It can be a primary problem or a symptom of another disease (a secondary headache)

4. CLASSIFICATION OF HEADACHE The IHS Classification System includes 1. Primary headache 2. Secondary headache  - identifiable cause 3. Painful cranial neuropathies and facial pain (Nerve fiber) II, III, IV, V, VI, VII, IX

5. 1. Primary Headache Migraine headache Tension-type headache  Trigeminal autonomic cephalalgias Other primary headache disorders

6. Migraine 1.1 Migraine without aura 1.2 Migraine with aura 1.3 Chronic migraine 1.4 Complications of migraine 1.5 Probable migraine 1.6 Episodic syndromes that may be associated with migraine

7. MIGRAINE WITHOUT AURA

8. MIGRAINE WITH AURA

9. Migraine with brainstem aura 2 of the following brainstem symptoms: Dysarthria,vertigo,tinnitus,hyperacusis,diplopia,ataxia,decreased level of consciousness Chronic migraine Headache (TTH-like and/or migraine-like) on ≥15 d/ mo for >3 mo Status migrainosus unremitting for >72 h and pain and/or associated symptoms are debilitating

10. Tension Type Headaches Headache lasting 30 minutes to 7 days with at least 2 of the following Pressure/tight ( nonpulsating ) quality Mild or moderate intensity Diffuse involvement No aggravation by walking stairs or other routine activity No nausea or vomiting Photophobia and phonophobia are not present, or only one

11. Cluster headache A. At least 5 attacks fulfilling criteria B-D B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 min (when untreated) C. Either or both of the following: 1 of the following ipsilateral symptoms or signs: a) conjunctival injection and/or lacrimation b) nasal congestion and/or rhinorrhoea c) eyelid oedema d) fore-head and facial sweating e) forehead and facial flushing; f) sensation of fullness in the ear g ) miosis and/or ptosis 2. a sense of restlessness or agitation D. Frequency from 1 per d ay to 8/d for > half the time when active E. Not better accounted for by another ICHD-3 diagnosis

12. SECONDARY HEADACHE Non serious Causes- Sinusitis Otitis Allergies Conjunctivitis Contusion Dental infection Postlumbar puncture headache Extraocular muscle strain Medication overuse headache

13. Serious Causes Meningitis(bacterial, viral,fungal , mycobacterial) Encephalitis Brain abscess SOL(Neuroblastoma, Glioma, Meningioma) Trauma ,Cerebral contusion, Subarachnoid haemorrhage,Subdural hematoma, Intracranial hemorrhage Cerebrovascular abnormality, Aneurysm Malignant hypertension Temporal arteritis Hydrocephalus/ Pseudotumorcerebri Glaucoma Hypoglycemia

14. KEY The diagnostic approach starts with a thorough history followed by a complete physical and neurologic examination

15. History Description of the headache Duration of illness Pattern Acute: URTI, trauma, systemic infection, and hemorrhage Acute recurrent: Migraine, cluster headaches, and tension type headache Chronic progressive: Brain tumor , chronic meningitis, and pseudotumor cerebri Chronic nonprogressive and mixed: Chronic migraine, malingering, and medication overus Frequency of attacks Duration of each attack Severity of pain (interference with activities) Location of maximal pain (frontal, temporal, occipital, sinus, periorbital) Quality of pain (throbbing, stabbing, squeezing) Pattern of previous headache

16. Trigger factors: Caffeine, hunger, noise, smell, stress, sleep, change in altitude, travel, etc. Associated symptoms H/o Trauma Autonomic symptoms Aura Past medication history Family history - Migrane typically run in family with 90% of children has 1 or 2 degree relative with recurrent headaches

17. EXAMINATION General appearance Ear ,Nose and throat Eyes – Papilledema Vital signs - (HR,BP,RR) Blood pressure is mandatory in a child with headache . Head and neck  - increased HC, Cranial trauma, Bulging AF Careful examination of the skin A thorough neurological examination is mandatory in any child with headache Assess the level of consciousness Evaluate cranial nerve function, tone, reflexes, strength, and sensation Evaluate the neck for nuchal rigidity Fundoscopic examination Some children with migraine can develop focal neurological abnormalities (ophthalmoplegia , motor weakness or ataxia)  

18. “SNOOPY” can be used to remember the red flags : S: Systemic signs and symptoms  N: Neurologic signs and symptoms O: Sudden onset O: Occipital location P: Previous headache history with new, worst, or different character of headache − Progressive nature − Precipitated by pressure and Valsalva maneuver − Postural component to headaches Y: Age <6 years

19. First or worst headache ever; sudden (“thunder­clap”) onset Increasing severity or frequency Change in headache character , Awakening from sleep because of headache Chronic or recurrent occipital headache Occurring exclusively in the morning or late at night Associated with severe vomiting, particularly in early morning Headache associated with straining ( cough,sneeze , urination, defecation) Poor response to therapy Abrupt alteration in mental status ,personality change, lethargy. Neck pain, history of VP shunt

20. Papilledema Skin findings Cranial nerve involvement Focal neurologic deficit any signs of meningitis High-risk populations (patients with sickle cell disease, immune deficiency, malignancy, coagu­lopathy, pregnancy, neurocutaneous syndromes, congenital heart disease, or recent head trauma)

21. INDICATON FOR NEUROIMAGING IN A CHILD WITH HEADACHE Abnormal neurological examination Abnormal or focal neurological signs and symptoms Seizures or very brief aura (<5 min) Unusual headache in children Headache in children less than 6 years Brief cough headache in a child Headache worst on first awakening or that awaken the child Migraine in a child without family history

22. Treatment The therapeutic management of headache in depends on general clinical conditions of the child and the presumable etiology of headache. For most cases of secondary headaches, treatment relies on addressing the primary problem.

23. Headache education: Patient and family should be reassured that there is no serious underlying disorder. It is helpful for the patient to keep a headache diary to identify patterns and triggers and to evaluate treatment response 2. Lifestyle modification: SMART headache management: • S leep: Regular and sufficient sleep • M eals: Regular and sufficient meals, caffeine avoidance, and good hydration • Activity: Regular aerobic exercise • Relaxation: Stress reduction and relaxation exercises • Trigger avoidance: Avoid sleep deprivation, fasting, and identifiable triggers

24. Acute management: It is advisable to prevent overuse of analgesics to prevent chronic and intractable headaches termed analgesic rebound headache

25. 2. Preventive treatment: Indications • Headache frequency at least one headache/week or more than three headaches/month • Prolonged and severe headaches, even if infrequent • Headache in which abortive treatment fails, overused or is contraindicated in the child Choice of drug depends on comorbid conditions associated with migraine. Topiramate : Preferred in obese child, avoided in child with renal stone (approved in children >12 years) Valproate: Thin built child, child having epilepsy (approved in adults) Amitriptyline: Teenager with sleep problems Propranolol: Not good for asthmatic and competitive athlete Cyproheptadine: In younger children, syrup available, child with allergic disorder

26. Biobehavioral techniques that may be successful include biofeedback therapy • Relaxation techniques • Hypnosis • Acupuncture • Massage therapy

27. TAKE HOME MESSAGE Importance of recognising primary and secondary headaches Know the RED FLAGS A normal neurological examination correlates well with the absence of relevant intracranial processes

28. REFERENCES Nelson 22 nd edition IAP STG 2022 International headache society – 3 rd edition

29. THANK YOU