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Title: Headaches%20and%20Head%20Injuries%20in%20Children%20and%20Adolescents%20Texas%20Children

Headaches and Head Injuries in Children and
AdolescentsTexas Childrens Hospital Advanced
Practice Provider ConferenceFebruary 7, 2014
  • Deanna Duggan, MS, RN, CPNP-PC, PMHS
  • Headache Clinic
  • Blue Bird Circle Clinic for Pediatric Neurology
  • Texas Childrens Hospital
  • Baylor College of Medicine

  1. Identify clinical presentation of primary and
    secondary headaches
  2. Identify up to date recommendations for
    management of secondary headaches attributed to
    head injury
  3. Assimilate medical and psychological
  4. Enable the pediatric provider how to construct an
    individualized headache treatment plan

  • Incidence and prevalence in the pediatric
  • Degrees of disability
  • Types
  • Accurate diagnosis is key
  • International Headache Society Classification
  • www.ihs-classification.org/en
  • Concussion vs. Traumatic Brain Injury

Examples of headache types described in ICHD-2
  • Part I The Primary Headaches
  • Tension-type Headache
  • Migraine (with or without aura)
  • Cluster Headaches and other Trigeminal Autonomic
  • Part II The Secondary Headaches
  • Headache Attributed to Head or Neck Trauma
  • Acute Post-Traumatic Headache
  • Chronic Post-Traumatic Headache
  • Acute Headache Attributed to Whiplash Injury
  • Post-craniotomy Headache
  • Medication Overuse Headache
  • Cervicogenic Headache
  • Part III Cranial Neuralgias, Primary and Central
    Causes of Facial Pain

  • Characteristics of the headache and headache
  • Baseline headache
  • Is there resolution of symptoms in-between
  • Consider other disorders or triggers
  • Mechanism of injury
  • Concussion Describe symptoms reported
    immediately after injury and days subsequent to
  • Is there a concussion history?
  • What makes the headache better or worse?
  • Physical and Neurological exam (including
  • Neuroimaging

Red Flags in the Diagnosis of Childhood Headaches
  • Escalating frequency and/or severity of headaches
    over several weeks (under 4 months) in a child
    under the age of 12, and even more importantly
    under the age of 7
  • A change of frequency and severity of headache
    patterns in young children
  • Fever is not a component of migraine at any age,
    especially in children
  • Headaches accompanied by seizures
  • Sensory disturbance may occur in certain forms of
    migraine, however, neurological attention is
    warranted to determine appropriate assessment and

  • Post concussion symptom checklist
  • Headache
  • Nausea/vomiting
  • Balance problems
  • Dizziness
  • Sensitivity to light
  • Blurred vision
  • Sensitivity to noise
  • Nervousness
  • Numbness/tingling
  • Feeling slowed down
  • Feeling like in a fog
  • Difficulty concentrating
  • Difficulty remembering
  • Neck pain
  • Fatigue/drowsiness
  • Difficulty sleeping
  • Sadness
  • Irritability

Symptoms are subjective - 38 of athletes
reporting no symptoms may still demonstrate
neurocognitive deficits (Broglio, 2008)
Define a concussion
  • Symptoms that may occur after injury to the head
    include at least one of the following Any period
    of loss of consciousness, any loss of memory for
    events immediately before or after injury,
    alteration in mental state at the time of injury
    and/or focal neurological deficits that may or
    may not be transient
  • Symptoms that may persist after injury
  • 1. loss of memory or AMS (dazed, disoriented,
  • 2. physical symptoms (nausea, vomiting,
    dizziness, HA, tinnitus, blurred vision,
    sensory loss, sleep disturbance or extended
    periods of fatigue/lethargy)
  • 3. cognitive deficits (attention,
    concentration, language, memory, perception)

  • 1. Observe
  • Aphasia or speech difficulty
  • Behavior
  • 2. Palpate
  • Head and neck for painful/tender areas,
    swelling or crepitus
  • 3. Assess
  • Neck ROM (active and passive)
  • Neck strength
  • Dermatomes and myotomes
  • 4. Stress tests
  • 3 Cs
  • Cognition
  • Coordination
  • Cranial nerves

Cognitive Screening Tools
  • SCAT2
  • SAC (sideline mental status tests)
  • CNS Vital Signs
  • CogSport
  • HeadMinder
  • ImPACT
  • Sports as a Laboratory Assessment Model (SLAM)
  • Automated Neuropsychological Assessment Metrics
  • Serial evaluations
  • Neuropsychological evaluation

What is cognitive rest?
  • Safety Guidelines
  • 1. Restrict physical activity until all
    symptoms COMPLETELY resolved
  • 2. Risk for Second Impact Syndrome (repeat
    concussion that occurs soon after initial
    concussion) - Result can be a rapid, catastrophic
    increase in pressure within the brain. Effects
    include physical paralysis, mental disabilities,
    and epilepsy. Death may occur approximately 50
    of the time.
  • 3. Plan for educational modifications specific
    to the patient per section 504 Other Health
    Impairment Traumatic Brain Injury
  • extended time to complete schoolwork or
  • testing in a separate room with decreased
    environmental stimulation
  • extended time to walk in-between
    classrooms, have small frequent meals, carry a
    water bottle and liberal bathroom privileges
  • allow for the patient to stop any educational
    activity should severe headache or other
    neurological symptoms exacerbate. In such case,
    child should be excused immediately
  • partial attendance or homebound

Traumatic headache/Concussion treatment Key
  • Symptom exacerbation following physical or
    cognitive activity is a sign that the brains
    dysfunctional neurometabolism is being pushed
    beyond tolerable limits
  • In guiding recovery, management of neurometabolic
    demands on the brain is crucial
  • Do not allow patients to exceed physiologic
  • Pay attention to over-exertion
  • - physical
  • - cognitive
  • Concussion is most common concussion-related
  • Migraine a risk factor for concussion?

  • Drink adequate amounts (calculate daily
    maintenance) of non-caffeinated fluids daily. OK
    to include Gatorade, Propel or other
    electrolyte-infused beverages
  • Maintenance Fluid requirements per body weight
    in kilograms
  • Eat 4 to 5 small, frequent meals including green,
    leafy vegetables (rich in vitamin B2 and
    coenzyme Q10)
  • Maintain regular sleep cycle of at least 8 (may
    need 10) hours per night
  • Avoid physical and cognitive strain. NO sports
  • Physical Therapy /Graduated Return to Play
    guidelines once patient is symptom free for at
    least 24 to 48 hours

1 10 kg 100 mL/kg
11 - 20 kg 1000 mL 50 mL/kg for each kg gt 10 kg
gt 20 kg 1500mL 20 mL/kg for each kg gt 20 kg
Management (continued)
  • Abortive Medications
  • 1. NSAIDS (ibuprofen, naproxen, etodolac,
  • 2. Antiemetics including Phenergan, Zofran,
    Compazine or Reglan 3. Triptans (Axert, Maxalt,
    Zomig, Relpax, Imitrex)
  • 4. DHE
  • 5. Depakote
  • 6. Dexamethasone or Medrol Pak
  • Other medications that might help
  • muscle relaxers (cyclobenzaprine, tizanidine)
  • Treatment goal Do NOT exceed 2 to 3 doses of
    analgesic medication in one week!

Other treatment strategies
  • Daily Preventative Medications
  • amitriptyline, topiramate (Topamax),
    propranolol, gabapentin, SSRIs
  • Supplementation (coenzyme Q10, riboflavin,
    chelated magnesium, Omega 3s)
  • Physical therapy
  • Occipital nerve block injections
  • Biofeedback
  • Cognitive Behavioral Therapy

Other headache factors/ Setbacks
  • Rebound headache (secondary headache)
  • Acute illness
  • Stress, Anxiety, Depression, ADHD and/or
    behavioral problems
  • Repeat injury
  • Any other chronic disease process

Points to take home
  • Education
  • 1. Call our office if headaches worsen or new
    neurological signs develop
  • 2. Anticipatory guidance
  • 3. Watch Head Games documentary

References and Resources
  • Winner, P., Lewis, D. Young Adult and Pediatric
    Headache Management, Hamilton, Ontario 2005
    page 1-232.
  • www.achenet.org
  • www.americanheadachesociety.org
  • Finkel, A., Guskiewicz, K., Dodick, D., and
    Conidi, F. Sports Concussion/Mild Traumatic
    Brain Injury and Headache. American Headache
    Society Scottsdale Headache Symposium, November
    10, 2011
  • Neal, M., Wilson, J. Wesley, H. and Powers, A.
    Surg Neurol Int 2012 316
  • Lau et al. Clin J Sport Med 200919 216-221
  • Register-Mihalik et al. Clin J Sport Med 2007
    17 282-288
  • Gordon et al. Br J Sports Med 2006 40 184-186
  • Wetjen et al. J Am Coll Surg. 2010 211 553-7
  • Halstead et al. Pediatrics. 2013 132 (5) 948-57
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