Paediatric Headache

ACEM Fellowship

May 10, 2020

Table of Contents

Introduction

Most common pediatric causes include febrile illnesses, ENT infections, migraines and tension headaches
75% of children suffer a headache by age 15
Red flag symptoms (RCH)
- Acute and severe
- Progressive chronic headaches
- Focal neurology
- <3yo
- Headache/vomiting on waking
- Consistent location of recurrent headaches
- Presence of VP shunt
- HTN
- Recent head injury

Headache patterns

A – Acute recurrent – Migraine
B – Chronic non-progressive – Tension, anxiety, depression, somatisation
C – Chronic progressive – Tumour, benign intracranial hypertension, brain abscess, hydrocephalus
D – Acute on chronic non-progressive – Tension with coexistent migraine

Headsmart guide (UK)

Has reduced total diagnostic intervanl (patient interval + diagnostic interval) from 14.4 weeks to 6.7 from first symptom/sign
Recommends in addition to below:
- Ask specifically about associated risk factors
  - Personal or FHx of brain tumor
  - Leukaemia
  - Sarcoma or early onset breast/bowel cancer
  - Neurofibromatosis type 1 or 2
  - Tuberous sclerosis
  - Li Fraumeni
  - FHx of colorectal polyposis
  - Gorlins syndrome
  - Other familial genetic syndromes
- Plot growth, pubertal status and head circumference (if under 2)

International headache society

Primary
- Migraine
- Tension
- Cluster and other trigeminal-autonomic cephalgias
- Diagnoses of exclusion
Secondary are what we worry about but differential is extraordinarily large
- Infection
- Bleed
- Tumour
- Trauma
- Dental/eye/sinus/ear
- Substance or its withdrawal (CO, lead, caffeine, alcohol)
- Psychiatric
Cranial neuralgias and primary facial pain

Three main questions

Is it a tumor?
Is it a bleed?
Is it an infection?

Is it a tumor?

Progression and worsening over time
Associated vomiting
Pain only in occiput
Worse with Valsalva
Waking from sleep
Worse in the morning
No FHx of migraine (70-90% of migraine headaches have FHx)
No associated aura with headache

Is it an infection?

If you think you might need to do an LP…you do
Sometimes obvious requirement to do LP
Difficulty is headaches with possible viral symptoms
- Reliable predictors of meningitis are rare:
  - Bulging fontanelle (8x)
  - Neck rigidity (8x)
  - Poor general appearance
  - Change in behaviour
- Unvaccinated?
What about fever?
- Only fever above 40 degrees makes meningitis more likely (LR + 2.9)
- Fever <40 does not make meningitis more likely

Is it a bleed?

Underlying disorder/chronic illness
- E.g. Sickle cell, hypertension, rheumatological disease, endocrine/metabolic disease
- Consider cerebral venous sinus thrombosis, vasculitis, ischaemia or haemorrhage
AV malformation is the haemorrhage we fear most
- Think Headache PLUS
  - Vomiting
  - Unilateral and new for patient
  - New seizure
  - Focal neuro deficit (may be transient due to vascular steal)

Examination

Vitals
Signs of meningism
Signs of trauma
Signs of NAI including retinal haemorrhages
Plot height/weight/pubertal status/head circumference (<2yo)
CVS – Coarctation of aorta (femoral pulses)
- Classic presentation is unequal pulses + headache

Neurological examination

98% of children with tumor will have one of 5 findings: Papilloedema, ataxia, hemiparesis, abnormal eye movements or depressed reflexes
Meticulous neurological examination is key
Papilloedema
Eye movements – 3rd or 6^th cranial nerve palsy may indicate raised ICP
Pronator drift – Unilateral drift indicates contralateral hemisphere mass lesion
Depressed deep tendon reflexes – Indicates contralateral mass lesion
Short stature or delayed puberty – craniopharyngioma
Torticollis – Posterior fossa tumour
Failed tandem gait – Posterior fossa tumour
Malar rash of lupus + Neurocutaneous syndromes

CT imaging

1/1500 risk of subsequent cancer directly related to that radiation exposure
Requires sedation and time
Abnormal neuro examination = Non-contrast CT
- If normal, admit for MRI +- LP (idiopathic intracranial hypertension)
Recent onset of severe headache, change in type of headache or associated features that suggest neurological dysfunction = Consider non-contrast CT (American Academy of Neurology 2004)
Recurrent headache = Outpatient MRI

PEMsoft
- High priority
  - Chronic and progressive headache pattern
  - Apparent severe headache <3yo
  - Severe acute headache (worst headache of life)
  - Focal neurology
  - VP shunt or neurocutaneous syndrome
- Moderate priority
  - Headache or vomiting upon waking
  - Vomiting with headache
  - Meningeal signs
  - Unvarying location of headache
  - Change in type of headache

How common are tumors?

Annual incidence of 3/100 000
Medina et al. Pediatrics
- Low-risk group 0.01% tumor
  - Non-migraine headache for 6 months as sole symptom with no neuro findings
- Intermediate-risk group 0.4% tumor
  - Migraine symptoms and normal neurological examination
- High-risk group 4% tumor
  - Headache PLUS
    - <6mo duration
    - Sleep-related
    - Vomiting
    - Confusion
    - Absence of visual symptoms
    - Absence of family history of migraine
    - Abnormal neurological examination

Tension headache

Tension headaches (50% of headache presentations)
- History
  - Band-like pressure with muscle aches in neck and shoulders
  - Pattern, exacerbating factors
  - Look for medication overuse (cephalgia medicamentosa) as NSAID’s 3 or more times per week is associated with this
    - Culprit in 50% of chronic headaches
- Rx – PO rehydration and NSAID/paracetamol

Tension headache criteria

Migraine headache

Migraines (25% of headache presentations but more common than tension in younger children)
- Under-diagnosed in children as rare but present differently to adults
  - Mostly bilateral and temporal in children
- Prevalence increases with age
  - Age 3-7: 2%
  - Age 7-11: 7%
  - Age 11-20: 20%
- May be complicated by hemiplegia, ophthalmoplegia, tinnitus, ataxia, weakness and paraesthesia

Migraine with aura criteria

Migraine treatment (RCH)

First-line: Paracetamol 15mg/kg +- Ondansetron
<12yo
- Ibuprofen 10mg/kg
- Chlorpromazine 0.15mg/kg IV in 20mL/kg N/S over 1 hour
>12yo
- Aspirin 1g PO
- Sumatriptan IN 10-20mg or SC 3-6mg
- Chlorpromazine 0.15mg/kg in 20mL/kg N/S over 1 hour

Cluster headache

Rare in children <10yo
Mainly boys >10
Unilateral frontal-parietal with ipsilateral autonomic findings
Several times in one day
Recur over weeks or months then may be headache free for 1-2 years
Rx: Triptans, O2 and prednisone

Idiopathic intracranial hypertension

Consider in any child who recently started new medication
Papilloedema may be only sign
Pressure >20cmH20 is diagnostic
May present with intermittent headache, vomiting, blurred vision or diplopia

Treatment of primary headache

Mild – PO hydration, short-course of NSAID +- paracetamol
RCH
- Mild – Paracetamol +- ondansetron (if vomiting)
- If migraine considered most likely
  - <12yo: Ibuprofen + Chlorpromazine 0.15mg/kg in 1L N/S over 1 hour (Largactil)
  - >12yo: Aspirin 1g PO, Sumitriptan 10-20mg IN (can repeat once)+ Chlorpromazine as above
- Resistant/severe (Kaar et al. Pediatric Emergency Care)
- 20mL/kg IV N/saline bolus +
- Ketorolac 0.5mg//kg (max 30mg)
- Diphenhydramine 1mg/kg (max 50mg)
- Prochlorperazine 0.1mg/kg (max 10mg)

Who to admit?

Any child with one or more red flags

Who to refer to gen paeds outpatients?

As per RCH guidelines
- 1-2 headaches/week
- Disabling headaches
- Missed >2/52 school

Discharge advice

Discharge advice
- Sleep well, exercise, adequate rest, limiting digital screen time, stress management, drink plenty of fluids
- HEADSS (Home/Education/Activities/Drugs/Sexuality/Suicide)
- If concerns re: recurrence/severity – headache diary and refer to primary care +- Neurology
- Avoid alcohol/caffeine
- Limit treatment with medications to 3 times per week
Consider optometrist review if suspicious of refractive error – document VA

Last Updated on November 10, 2021 by Andrew Crofton

Andrew Crofton