Headache in Children -Current Perspective.pptx

This presentation describes Current Perspectives for the management of Headache in Children

1. Headache in Children & Adolescents Moderator

2. Prof. P.A.M. Kunju MD DM WHO Fellow in Neuro (USA) Prof of Pediatric Neurology KIMShealth Trivandrum Dr . DIGANTA BARMAN MD Prof. Pediatrics, . Dr. Seba Ranjan Biswal DR RADHA KRISHNA SINHA DR S SRINIVASA

3. 1. DR DIGANTA BARMAN, India 2. Dr. Seba Ranjan Biswal, India 3. DR RADHA KRISHNA SINHA, India,  5. DR S SRINIVASA, India

4. Contrary to the common belief headaches is a common symptom in children By six years of age, 39% & by age 15, 70% suffer from headache 20% of adults have the onset before age 10.

5. Most headaches in children are benign. Headaches impact the lives of children, resulting in school absence, decreased extracurricular activities, and poor academic achievement. Frequently symptoms other than pain may be overwhelming

6. Easy 3s 3 3 3 3 3

7. ?

8. 10 yr old boy migraine with aura – zigzag line in front of eye followed by black spots , now refuses to come out of room , keeps ear closed ; already had Paracetamol 250 mg No relief What next? Dr . DIGANTA BARMAN 1

9. Treating the Attack 15mg/kg = 45 kg x 15 =675mg Sufficient dose

10. Acute therapy outpatient The use of metoclopramide / Domperidone 10 mg PO may enhance the efficacy of oral medication. P/L +Domp

11. Triptans Sumatriptan Naratriptan is a second generation 5-HT1D receptor agonist, and z olmitriptan and Rizatriptan are selective 5-HT1D/1B receptor agonists

12. Oral sumatriptan 50 to 100mg 6 mg SQ; may repeat in 1 hour; maximum 12 mg/24 hours

13. Mouth dissolving diclofenac Drugs Dr Kunju

14. Case 14 yr old girl about to write 10 th exam. Severe episodic headache. Migraine attacks since 7 yr. Mother also has migraine. For attacks tried Paracetamol 650mg. Then sumatriptan was advised by a neurologist. Still attacks are severe and cannot study. Further possibilities of acute attack? Dr. Seba Ranjan Biswal 2

15. Combination Sumatriptan + naproxen Ketorolac Triptan -NSAID Combinations

16. Acute therapy (Emergency room) Above 6 yrs- Triptans Oral sumatriptan 25 to 100mg;6 mg SQ; may repeat in 1 hour; maximum 12 mg/24 hours Naratriptan 1 mg

17. Intranasal atriptan

18. triptan

19. Step care through attack Stratified care

20. 8yr o boy Severe headache 2 time/mo - last 3 mo Lost school days Last headache 2 weeks back What action? Case DR S SRINIVASA 3

21. Prophylactic treatment Prophylaxis is indicated, if (1) Patient has more than 2 migraine attacks per month (2) Patient has single attacks that last longer than 24 hours (3) Headaches cause major disruptions in the patient's lifestyle (4) Abortive therapy fails or is overused (5) Patient has complicated migraine

22. Prevention Flunarizine 5 or 10 mg/day - 0.1-0.3 mg/kg/day Adverse effects bodyweight gain and drowsiness Propranolol 1-2 mg/kg/day Contraindicated in asthma, heart failure, and diabetes Amitriptyline - 10mg ½ bed time Topiramate – 1-6 mg/kg Valproic acid – 10- 20 mg/ kg

23. Inspite of taking above medications ( Flunarizine + Propranolol ) monthly one attack What advice? DR S SRINIVASA 4

24. Recommended bio-behavioral program 1. Good sleep hygiene Regular sleep schedule Avoid excess, inadequate, or chaotic sleep 2. Regular aerobic exercise (30 minutes/day) 3. Regular meals, avoid missing meals 4. Caffeine avoidance/moderation 5. Dietary adjustments “Avoidance” diets 6. Identification of migraine triggers

25. 9yr old girl Monthly abdominal pain Had repeated USG abdomen Frequent admission with IV fluids Multiple consultations to G enterologists and Paediatric surgeons What will be your diagnosis and approach? DR RADHA KRISHNA SINHA 5

26. Cyclical vomiting syndrome Diagnostic criteria: > 5 attacks of N&V, fulfilling criteria B & C B.Stereotypical with predictable periodicity C.All of the following: N&V occur at least four times per hour attacks last for ≥1 hour, up to 10 days attacks occur ≥1 week apart D.Freedom from symptoms between attacks E. Not attributed to another disorder.

27. Periodic Syndromes of Childhood” that Represent Precursors of Migraine Episodic syndromes that may be associated with migraine Four childhood conditions Cyclic vomiting syndrome - Amitriptyline Benign paroxysmal vertigo- Trial of cyproheptadine (2 to 4 mg) orally at bedtime for 4 to 6 weeks; Betahistine ; Propranolol Abdominal migraine Benign paroxysmal torticollis

28. Describe types of special migraine with aura ? Dr . DIGANTA BARMAN 6

29. 3 types of special migraine with aura are, 1.Hemiplegic migraine FHM1 -CACNA1A gene ;FHM2 -ATP1A2 gene (coding for a K/Na-ATPase); FHM3- SCN1A gene  2. Basilar migraine- Brain stem symptoms visual disturbances, diplopia, tinnitus, vertigo, ataxia, and bilateral weakness Migraine with brainstem aura (ICHD3) 3.Ophthalmoplegic migraine Duration between 30 minutes to a month

30. Recent onset-severe headache Vomiting. Wake up at 2.00 AM No relief with multiple analgesics How to approach? Case Dr. Seba Ranjan Biswal 2

31. Secondary headache

32. LR palsy

33. Can you please Enumerate the Causes of secondary headache Dr. Seba Ranjan Biswal 7

34. Secondary headache Tumor Meningitis Subarachnoid haemorrhage Traction & Inflammatory HA

35. Secondary headaches Infections---Sinusitis, OM, Meningitis, Encephalitis 2. Trauma-----Head/Neck 3. Vascular----Cranial/Cervical 4.Non vascular intracranial -Raised/low ICP, post -epileptic, ICSOL

36. Secondary headache contd.. 5.Substance Abuse…. withdrawl /overdose 6.Facial Pain from cranium, neck, eyes, ears, nose, sinuses, teeth, mouth etc 7.Disoeders of homeostasis 8.Psychiatric Disorders

37. How to make a diagnosis of primary headache? DR S SRINIVASA 8

38. Tension Type Head ache Bilateral ( Frontal/ Temporlal )

39. Trigeminal autonomic cephalalgias (TACs) Cluster headache at least one of the following symptoms or signs, ipsilateral to the headache: – conjunctival injection and/or lacrimation – nasal congestion and/or rhinorrhoea – eyelid oedema – forehead and facial sweating – miosis and/or ptosis a sense of restlessness or agitation Occurring with a frequency between one every other day and 8

40. 2ndary headache How will you suspect? 9 Radhakrishna sinha

41. Look for Warning signs of headache Neurological disturbance, Clumsiness or weakness Cognitive dysfunction- i School performance Change in pain character Pain always on one side

42. Warning signs in head pain Change in pain character Cognitive dysfunction- i School performance Neurological disturbance, Clumsiness or weakness Pain always on one side

43. In a child with Migraine headache when will you order an MRI? DR RADHA KRISHNA SINHA 10

44. ++ early morning VOMITING ALWAYS ON ONE SIDE LOW GRADE FEVER

45. Some clues for a post fossa tumour Ataxia Torticollis

46. Post Fossa Tumour with Hydrocephalus PAMkunju © PAMkunju © PAMkunju © PAMkunju © PAMkunju ©

47. Brain stem auditory evoked response (BERA)

48. CP Angle tumor

49. Case Hydrocephalus on . VP Shunt Severe headache No fever; What will be the problem Any simple test? Complication ? Dr . DIGANTA BARMAN 11

50. Broken Shunt

51. Intact shunt

52. ACM

53. Diet in migraine 12 Dr. Seba Ranjan Biswal

54. Alternative therapies Dr sreenivasa 13

55. Newer modalities for migraine? Dr Radakrishna Transient receptor potential vanilloid type 1 antagonists Prostaglandin E receptor 4 receptor antagonists Serotonin 5HT1(F) receptor agonists Nitric oxide synthase inhibitors 14

56. Take home

57. S Close range & refractory error Triggers How long have you been watching Cartoons All my life

58. Certain foods,Alcohol Triggers

59. Comprehensive Headache evaluation Headache Types Treatment

60. Easy 3s 3 3 3 3 3

61. Migraine ( Hemicrania) Tension type Cluster

62. Migraine Unilateral Pulsating Moderate /Severe

63. Migraine With Aura

64. Hemicrania Detect early Treat early!11!! Thank you!!!

65. IAP 04/01/24