Organic Causes of headaches

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Organic Causes of headaches

• Brain tumours
• CNS infection(TB, chronic meningitis, abscess)
• Arterial hypertension and vascular malformation
• Benign increase intracranial pressure
• Hydrocephalus and congenital malformation
• Para nasal sinusitis
• Endocrine and metabolic causes ( hypoglycaemia)

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Clinical examination

• Look to skin
• Wt, Ht and and head circumference
• Listen for cranial bruits
• Blood pressure
• Detailed CNS and systemic examination (optic
  disc, eye movements, motor asymmetry,
  coordination, and reflexes)

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Indications for neuroimaging

• High priority
• Acute headache
• Chronic progressive headache
• Abnormal or focal neurological abnormalities
• Papilloedeama
• Neurocutaneous syndromes (NF or TS)
• Younger age lt 3 years
• Vomiting on awakening
• Low priority
• Chronic nonprogressive headache
• Mixed headache
• Classic or common migraine
• meningeal signs
• variation in headache location

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Indications for Neuroimaging in 78 paediatric
patients with headaches by Maytal et al, Ped.
Vol 96.1995413-417

• Headache onest at younger age (lt5yrs) 4
• Increasing severity or frequency of headache 5
• Abnormalities on ocular or neurological
  examination 6
• Headache provoked by changing position of head 2
• Focal symptoms or signs during headaches 7
• Systemic symptoms e.g. weight loss, fatigue
  11
• Doctors and parents concern about cerebral mass?
  12
• Doctors and parents concern about cerebral mass?
  11
• Not specified 12
• Atypical headache pattern 12

5

• Finding by Amytal et al suggested that finding
  abnormalities on brain imaging in children with
  chronic headaches is at most 3.8
• Atypical headache pattern
• Any seizure
• Focal signs and symptoms
• Very young patients with unreliable history
• Clinical indications or suspicion
• Well defined migraine neuro-imaging not warranted

6
Management of Headaches

• Depend on the cause
• Frequency
• regularity
• Severity
• Impact on life style
• Reassurance is more important in migraine and
  tension type headache

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Drugs In use for both migraine and headache

• Acetaminophen
• Ibuprofen
• Codeine phosphate
• Ergot derivative (avoid in children)
• Propranolol
• Clonidine
• Phenytoin and phyenobarbiton, Carbamazepine,
  Gabapentin, Sodium Valproate and Lamotrigine
• Calcium channel blocking (nifedipine,
  cyproheptadine, flunarizine
• Triptans 5ST1B/1D (e.g. sumatriptan)
• prophylactic (use for those with severe symptom
  or migraine effects their education
• Abortive

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Anti-emetics which may be used in the treatment
of Nausea and vomiting accompanying childhood
migraine

• Promethazine (phenergan)
• Trimethobenzamide (Tigan)
• Prochlorperazine
• Methoclopramide
• Hydroxyzine

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Triptans (5-HT1B/1D receptor)

• No approval for use in lt16 years old
• Early studies on safety and efficacy are
  encouraging
• Contraindicated in hemiplegic, basilar artery
  migraine and allergic reaction
• Can be given orally, Intranasaly or IM
• Can be used as abortive as it work within 10
  minutes
• Side effects

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What said about Triptans use in Children

• Paul Winner, Paediatrics Vol.106 No 5, 11/200
• (Sumatriptan Nasal spray is effective and well
  tolerated for rapid relief of migraine in
  Adolescent in dose of 20mg which provide best
  efficacy and tolerability)
• Uberall M, Neurology,52, 1507-1510, 1999
• ( Small group placebo controlled study for
  children lt10 years of age with migraine,
  Sumatriptan NS of 20mg provided significantly
  more headache relief 2 hours post dose compare
  with placebo)
• Linder S,Headache, 36, 419-422, 1996
• (Subcutaneous Sumatriptan used in 6-16 year of
  age with migraine at dose of 0.6mg/kg is
  effective in alleviating migraine attack)

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Case history 1

• A 10 year old boy with history of headache for 4
  weeks
• Started as funny feeling inside his abdomen
• Pain round the right eye
• Pain spread all over his head
• Vomit
• Photophobia
• Fatigue, lethargic and want to sleep
• Ibuprofen helping him but mother not keen on
  medication
• School missing average 2 days per week
• No Cranial CT or MRI
• Tried pizitofen no success
• Respond well to Propranolol and stopped after
  three months

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Case history 2

• 7 year old boy with history of frequent headaches
  for the last 4 months
• Not responding to paracetamole and Ibuprofen and
  Codeine
• Not associated with vomiting
• CNS , eye, ears, and systemic examination were
  normal
• Cranial CT
• More anxiety
• Second opinion and MRI
• Respond to clonidine initially and then stopped
  all medications

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Cisterna Megna
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Key Points

• Headache is more common in teenagers
• History and examination is important to exclude
  pathology
• Definition of Children migraine is not always
  like adults
• 90 of population will have headache
• Neuroimaging not indicated in every cases( acute
  and progressive headache)
• Treatment can be supportive as well as medication
  may help
• Consider other causes when stuck

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