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Management of Pediatric Headaches


Diagnosis. Evaluation. Treatment. Migraine vs Tension-type / IHS ... Diagnosis: ICHD-II a step in the right direction for the Pediatric Population ... – PowerPoint PPT presentation

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Title: Management of Pediatric Headaches

Management of Pediatric Headaches
  • Paul Winner DO, FAAN, FAAP, FAHS
  • Palm Beach Headache Center
  • Clinical Professor of Neurology
  • Nova Southeastern University
  • Disclosure Speaker, Research, Consultant for
  • A-Z, GSK,Ortho McNeil, Merck, Pfizer, Allergan
  • Off label Medication use with be discussed

Management of Pediatric Headache Issues
  • Diagnosis
  • Evaluation
  • Treatment

Migraine vs Tension-type / IHS
Migraine Criteria
  • ? 5 attacks lasting 472 hours (30 minutes7
  • ? 2 of the following
  • Unilateral (bilateral)
  • Pulsating (not pulsating)
  • Moderate or severe intensity (mild or moderate)
  • Aggravation by routine physical activity (not)
  • ? 1 of the following
  • Nausea and/or vomiting (no nausea/vomiting)
  • Photophobia and phonophobia (one or neither)
  • No evidence on history or examination of disease
    that might cause headaches

Adapted from The International Classification of
Headache Disorders. Cephalalgia. 2004
Diagnostic criteria ICHC -II Migraine without
  • Notes
  • 3. In children, attacks may last 1-72 hours
    (although the evidence for untreated durations of
    less than 2 hours in children requires
    corroboration by prospective diary studies).
  • 5. Migraine headache is commonly bilateral in
    young children an adult pattern of unilateral
    pain usually emerges in late adolescence or early
    adult life.
  • 6. Migraine headache is usually frontotemporal.
    Occipital headache in children, whether
    unilateral or bilateral, is rare and calls for
    diagnostic caution many causes are attributable
    to structural lesions.
  • 8. In young children, photophobia and phonophobia
    may be inferred from their behaviour.

Proposed Criteria for Pediatrics
  • At least 5 attacks
  • Duration 1 to 72 hours
  • Two of the following
  • Bifrontal/bitemporal or unilateral
  • Pulsating / throbbing quality
  • Moderate to severe intensity
    (numerical scale, faces scale)
  • Aggravated by physical activity
  • One of the following
  • Nausea and/or vomating
  • Two of five symptoms (photophobia,
    phonophobia, difficulty thinking,
    lightheadedness, or fatigue)
  • May be inferred from their behaviour
  • 0 to 10 scale or faces scale can be used

A Look at the Future Solutions?
  • Recognition - Case based headache
  • Picturing Drawing based diagnoses
  • Allodynia Criteria
  • Disability Better assess degree
  • Quick Screen - Diagnostic tools
  • Continued Research
  • - Prospective diary studies
  • - Longitudinal studies

Childhood Periodic Syndromes
1.3.1 Cyclical vomiting 1.3.2 Abdominal
migraine 1.3.3 Benign paroxysmal vertigo of
1.3.1 Cyclical Vomiting
  • Description Recurrent episodic attacks, usually
    stereotypical in the individual patient, of
    vomiting and intense nausea. Symptom-free between
    episodes. Complete resolution of symptoms between
  • Diagnostic criteria
  • A.  At least 5 attacks
  • B.  Episodic attacks of vomiting and intense
    nausea, stereotypical in the individual patient
    from 1 hour to 5 days.
  • C. . Peak vomiting intensity at least 4
  • D. Symptom free between attacks
  • E. History and physical examination do not
    show signs of gastrointestinal disease.

1.3.2 Abdominal Migraine
  • Description An idiopathic recurrent disorder
    seen mainly in children of episodic midline
    abdominal pain manifesting in attacks lasting
    1-72 hours with normality between episodes. The
    pain is of moderate to severe intensity and
    associated with vasomotor symptoms, nausea and
  • Diagnostic Criteria
  • A.   At least 5 attacks fulfilling B-E.
  • B.   Attacks of abdominal pain lasting 1-72
    hours (untreated or unsuccessfully treated)
  • C.   Abdominal Pain has all of the following
  • 1.     Midline location, periumbilical or
    poorly localized
  • 2.     Dull or just sore quality
  • 3.     Moderate or severe pain intensity
  • D.  During abdominal pain at least 2 of the
  • 1.     Anorexia
  • 2.     Nausea
  • 3.     Vomiting
  • 4.     pallor
  • E.   History and physical examination do not
    suggest gastrointestinal or renal disease or such
    disease is ruled out by appropriate

1.2 Migraine with aura
1.2.1 Typical aura with migraine headache
1.2.2 Typical aura with non-migraine
headache 1.2.3 Typical aura without
headache 1.2.4 Familial hemiplegic
migraine 1.2.5 Sporadic hemiplegic
migraine 1.2.6 Basilar type migraine
1.2.4 Familial hemiplegic migraine
  • B. Aura consisting of fully reversible MOTOR
    WEAKNESS and gt1 of
  • 1. Fully reversible visual symptoms including
    positive and/or negative features
  • 2. Fully reversible sensory symptoms including
    positive and/or negative features
  • 3. Fully reversible dysphasic speech
  • D. At least one 1st or 2nd degree relative
    fulfils these criteria

Risk Factors/Suspected Causes of Frequent
  • Frequency of migraines(gt4/mo)
  • Overuse of medications, esp. analgesics /-
  • Depression
  • Stress or traumatic life events
  • Personality traits (e.g., neuroticism, type A)
  • Hypertension
  • Dietary triggers (caffeine)
  • Obesity
  • Low education/socioeconomic status
  • Head injury
  • Snoring

  • Adapted with permission from Walter Stewart, MD,
    MPH. Scher AI, et al. Pain. 200310681-89.

Chronic Daily Headache
4.8 New daily-persistent headache
  • Description Headache that is daily and
    unremitting from very soon after onset (within 3
    days at most). The pain is typically bilateral,
    pressing or tightening in quality and of mild to
    moderate intensity. There may be photophobia,
    phonophobia, or mild nausea.
  • Diagnostic criteria
  • A. Headache for gt 3 months fulfilling criteria
  • B. Headache is daily and unremitting from
    onset or from lt 3 days from onset¹

Treatment of Pediatric Headaches
Acute Treatment
  • Analgesics
  • NSAIDs
  • Triptans (5-HT agonists)
  • Antiemetics
  • Opiates

Preventive Treatment
  • Anticonvulsants
  • Antidepressants
  • Beta blockers
  • Calcium channel blockers
  • Serotonin agents

Pediatric Headache Issues
  • Diagnosis ICHD-II a step in the right direction
    for the Pediatric Population
  • Improve Diagnostic tools
  • Expanded Treatment Options
  • Continue Research
  • - Prospective diary studies/Longitudina
    l studies
  • - Acute and Preventative
    Clinical trials