UC Combined Conference

Headache August 11, 2010

Brad Sobolewski, MD Cincinnati Children’s Hospital Medical Center

Today we will discuss…

The evaluation and workup of headaches

in the Pediatric ED

When you should be worried about bad

causes for headaches (tumors)

When to get a CT scan

How to treat migraines

Struggling to stay awake? Follow along and answer the

five high impact questions on the handout

Etymology

The basics

Our job is to make the distinction between “bad” and benign headaches

History and physical help us diagnose most headaches

Brain tumors are rare, and will (almost always) have associated history and exam findings

Background

Common causes of headaches in the ED

Headaches associated with viral infection

and fever

Due to vasodilation from increased blood flow

Sinusitis

Migraine

Post traumatic headache

Tension headache

Rare causes of headaches that we worry about

Brain tumors

Intracranial hemorrhage

Hydrocephalus

Pseudotumor cerebri

A common occurrence

75% will have had a headache by age 15

Most are treated at home

Stats from a Pediatric Neurologist at CCHMC

Of the headaches referred to the ED…

Serious neurological diagnosis (6%)

Meningitis, shunt malfunction, hydrocephalus,

metastatic tumor

All had an abnormal neuro exam

Most common etiology - Viral infections with fever

Migraine (20%)

Pathophysiology

Extracranial structures directly sense pain

Sinuses, ears, scalp, muscles

The brain and its lining does not

Intracranial vessels can sense pain

The location of pathology may not directly

correlate with location of pain

Headache from “eye strain” is rare in

children

Differential diagnosis

Muscle Contraction Tension headache

Inflammation Infectious causes

(meningitis, sinusitis)

TMJ

Traction/Compression Intracranial hemorrhage

Tumors

Pseudotumor cerebri

Hydrocephalus

Persistent CSF leak after LP

Psychogenic

Vascular Fever

Migraines

Hypertension - vessel dilation and increased ICP

Hypoxia - causes cerebral vasodilation

CO poisoning, near drowning

Chronic disease exacerbation (CF, cyanotic heart disease)

History and

Physical Exam

Take a good history

Is the onset is sudden or gradual?

Abrupt onset + severe pain could be a ruptured AVM

Location?

Severity?

Unreliable in young children

Has this happened before?

Frequency and duration?

Constant (for days) yet can go to sleep - tension or psychogenic cause

Take a good history

Associated symptoms?

Visual or motor symptoms – migraine with

aura

Fever and mental status changes -

encephalitis

After trauma?

Have you tried any therapies?

Has it caused you to miss school or work?

Take a good history

Past medical history

CF and cyanotic heart disease – hypoxia

Renal disease – hypertension

Family history

“Migraine” may be used to describe any manner of chronic headaches

Environmental factors

Abrupt onset of headache and nausea in several family members? Think CO poisoning

Take a good history

Think about the following if the headache…

Awakens from sleep or upon awakening each morning – brain tumor

Starts later in the day – tension, migraine

Is worse when bending over – sinusitis

In an overweight (female) adolescent with newly impaired vision - pseudotumor cerebri

Physical exam

Vital signs - Get an

accurate BP!

Pro Tip: Abnormal

neuro exam

findings in children

with headaches

are rare

Physical exam - HEENT

Macrocephaly Hydrocephalus

Scalp Hematoma in unwitnessed trauma (abuse or

otherwise)

Auscultation through fontanelle could reveal the bruit of an AVM

Eyes Assess visual acuity and visual fields

Sluggish pupil – mass effect

Impaired EOM – orbital infection

Look at the fundi for papilledema

Physical exam - HEENT

Ears Otitis media/externa

Mastoiditis (exam findings)

Facial tenderness and erythema – maxillary and frontal sinusitis

Teeth – dental abscess

Pharynx – pharyngitis

Neck Nuchal rigidity – meningitis, ICH, tumor

Won’t/can’t look up – RPA

Assess the site of a VP shunt

Physical exam - Skin

What diseases are these skin lesions associated with?

Café au lait spots

Neurofibromatosis

Ash leaf spots

Tuberous sclerosis

Physical exam - Neuro

New focal findings are bad Some migraine patients have ophthalmoplegia,

extremity numbness – but this is not new

Mental status Depressed? Elevated ICP, bleed, mass

Cranial nerve abnormalities ICP, direct nerve compression

Sensory and motor function

Gait

Age appropriate fine motor coordination

Workup and

Evaluation

Workup

Labs

Appropriate if you are considering a severe systemic illness or infection

Lumbar puncture

If you suspect a mass lesion or a bleed CT first

If CT is negative in a suspected subarachnoid bleed

In pseudotumor cerebri get an opening pressure

Imaging

Xrays are useless – unless doing a shunt series

CT

For ICH, hydrocephalus, edema, herniation

Not high rez for masses, especially posterior fossa

To CT or not to CT…

Who should you scan? (Medina, 1997 and Lewis, 2007)

Persistent H/A and duration <6 months that hasn’t

responded to medical treatment

Abnormal neurologic findings (especially papilledema,

nystagmus, gait/motor abnormalities, seizures)

Severe, acute, and no FHx of migraines

Persistent H/A with substantial episodes of confusion,

disorientation, or emesis

Awakens from sleep or occurs immediately on awakening

FHx or PMHx of disorders that may predispose to CNS

lesions

Signs of elevated ICP

What about MRIs?

Great resolution for masses

Less available in all institutions at all hours

Requires patients to be still

Do you want to sedate a child with an abnormal neuro exam?

Generally can be done within 24-28h as outpatient

Summary of headache red flags

Sudden onset or onset during exertion

Abnormal neuro exam

Seizure

Worsening under observation

Abnormal vital signs (fever, Cushing’s VS)

First/worst (severe) headache

New onset headaches in patient with cancer, immunodeficiency

Fever?

Meningeal signs

Elevated BP

Abnormal neuro exam

Transient motor disturbance +/- prodrome

+/- relieved by sleep

Brain tumor

ICH

pseudotumor

Hypertension

Meningitis

Viral encephalitis

Other neurologic deficit

Brain abscess

Viral syndrome

Sinusitis

Dental abscess

Systemic illness

Migraine

Trauma

Posttraumatic headache

Stress +/- other somatic

complaints +/- depression

Tension/psychogenic headache

Fever?

Meningeal signs

Elevated BP

Abnormal neuro exam

Transient motor disturbance +/- prodrome

+/- relieved by sleep

Brain tumor

ICH

pseudotumor

Hypertension

Meningitis

Viral encephalitis

Other neurologic deficit

Brain abscess

Viral syndrome

Sinusitis

Dental abscess

Systemic illness

Migraine

Trauma

Posttraumatic headache

Stress +/- other somatic

complaints +/- depression

Tension/psychogenic headache

Illustrative Cases

Case #1

A 14 year old male has fever to 101oF, headache and neck stiffness

No history of trauma

Neuro exam is normal

He has pain with neck flexion

He had diarrhea two days ago, and “just feels tired”

Viral meningitis

A little bit about viral meningitis

Enterovirus is responsible for 90%

Older children have fever, headaches (usually retro-orbital or frontal), and photophobia

More than 50% of patients older than 1-2 years old have nuchal rigidity

Do we do an LP in suspected viral meningitis in a well appearing patient with a normal neuro exam?

The CSF features of viral meningitis and bacterial meningitis overlap

Definitely tap if Ill-appearing or signs of encephalitis

Case #2

A 7 year old male has a two month history of headaches upon awakening in the morning

He also has morning vomiting

The symptoms are getting worse

The neuro exam is normal

Historical findings in patients with brain tumors

Nocturnal headache/pain when arising in the AM

Worsening over time

Associated with progressively worsening

vomiting

Note: migraines can make you puke too

Behavioral changes

Polydipsia/polyuria (craniopharyngioma)

Probable neurologic deficits

Ataxia, clumsiness, blurred vision, diplopia

Honig PJ, Charney EB. Children with brain tumor headaches: distinguishing features.

Am J Dis Child 1982; 136: 121-141.

What if you suspect a brain tumor?

First, order a CT…

If negative and…

No signs of elevated ICP

Normal neuro exam

You can D/C home provided that they can get

evaluated and get MRI within 24-48h

Tell parents to bring kid back to ED for…

Clinical deterioration

Mental status changes

Vomiting

Case #3

A 15 year old female with no previous history of headaches presents with a pounding frontal headache and nausea

Prior to the headache she had left arm weakness and tingling that lasted for 30 minutes

Her mom thinks that she’s having a stroke like their dead grandma

Migraine pathophysiology

Due to a hyperexcitable cerebral cortex

Pain is due to extracranial vascular dilation

Calcium channel activation

Plasma proteins leak from dilated vessels leading to

sterile inflammation

Intracranial vasoconstriction also has a role

Trigeminal pain fibers are hyperexcitable too

Other external stimuli can worsen pain sensation

(allodynia)

Migraine headaches

Two main types

Migraine with aura

Migraine without aura

Also…

Acute migraine

Status migrainosus

Migraine variants

Migraine precursors

Migraine without aura

A simple mnemonic to help remember the common symptoms of migraine without aura

Photophobia

Unilateral

Nausea

Throbbing

Diagnosis of migraine without aura

A. At least five attacks fulfilling criteria B-D (below)

B. Headache attacks lasting 1 to 72 h

C. Headache having at least two of the following characteristics:

Unilateral location, may be bilateral, frontotemporal (not occipital)

Pulsing quality

Moderate or severe pain intensity

Aggravation by or causing avoidance of routine physical activity (eg, walking, climbing stairs)

D. During the headache, at least one of the following:

Nausea or vomiting

Photophobia and phonophobia, which may be inferred from behavior

E. Not attributed to another disorder

Migraine with aura

Common aura symptoms

Visual disturbances

Hemiparesis

Aphasia

The aura – transient, focal somatosensory

phenomena

Due to regionalized depolarization and

hypoperfusion

Migraine with aura

Visual disturbances (15-30%)

Occur before, or as the

headache starts

Scotoma 77%

Distortion or hallucinations

16%

Monocular visual

impairment 7%

Hachinski VC, Porchawka J, Steele JC. Visual symptoms in the migraine

syndrome. Neurol. 1973;23 :570 –579

Diagnosis of migraine with aura

A. At least two attacks fulfilling the criteria B-D (below)

B. Aura consisting of at least one of the following, but no motor weakness:

Fully reversible visual symptoms, including positive features or negative features (eg, flickering lights, spots, or lines)

Fully reversible sensory symptoms, including positive features (ie, pins and needles) or negative features (ie, numbness)

Fully reversible dysphasic speech disturbances

C. At least two of the following:

Homonymous visual symptoms or unilateral sensory symptoms

At least one aura symptom develops gradually over 5 min or different aura symptoms occur in succession over 5 min

Each symptom lasts 5 min and 60 min

D. Not attributable to another disorder

Other migraine variants

Basilar migraine 3-19% childhood migraines

Average age = 7

Dizziness, vertigo, visual disturbances, diplopia, or ataxia, followed by an occipital headache

Familial hemiplegic migraine Autosomal dominant inheritance

Transient hemiplegia precedes headache by 30-60 minutes

Headache can be contralateral to focal deficits

Postconcussion migraine Can be acute or subacute

Occurs with and without aura

Treatment is similar to conventional migraines

Migraine precursor syndromes

Cyclic vomiting syndrome Recurrent stereotypical episodic attacks of nausea

and vomiting

Symptoms resolve completely between attacks

Occur every 2-4 weeks and last 1-2 days

Treated with Cyproheptadine, amytriptylene, depakote, propranolol, or verapamil

Abdominal migraines School age children with episodic, vague, midline or

periumbilical abdominal pain

Last for hours

Do we manage migraine with aura and variants differently?

If the migraine with aura or migraine variant is hard to differentiate from a stroke – then work it up as such and consult Neuro early

No imaging if…

The history is typical ,

The aura is purely visual and <60 minutes

Neuro will get an outpatient MRI

Image to rule out stroke in the ED if…

The aura is atypical (motor or sensory)

The aura lasts >60 minutes

History of headache is new (<6 months)

If the migraine with aura is recurrent and closely matches previous symptoms then a big workup isn’t necessary

Outpatient abortive therapy…

What have they already taken at home?

Outpatient abortive therapy…

Does it work?

Ibuprofen (Lewis, 2000) is superior to placebo at 2

hours with decreased recurrence rate

Can it backfire?

Yes! Beware analgesic withdrawal headache

Gradual increase in medications leads to chronic

headache

Can occur with migraine

Low dose daily use may be worse than high dose

Treatment is stopping meds/caffeine

Preventative options

ED migraine treatment goals

Make the symptoms go away

Restore function

Align patient for outpatient follow up

Discharge instructions

Avoid triggers

Get good sleep, exercise, moderate caffeine intake, stay hydrated

Caution against analgesic overuse headache

IV management in the ED

Analgesics

Ketorolac 0.5 mg/kg IV or IM (max 30mg)

Antiemetics that also have analgesic properties

Prochlorperazine (Compazine) 0.1-0.15 mg/kg IV

(max 10mg)

Metoclopramide (Reglan) 0.5-2 mg/kg IV (max 20mg)

Also give the patient some IV fluids

Typically a 20ml/kg NS bolus over 1 hour

IV management in the ED

Side effects/things to watch out for

Ketorolac – make sure you’re not concerned

about a bleed, and that females aren’t

pregnant

Prochlorperazine – can cause restlessness,

agitation, and in rare instances a dystonic

reaction - treat with benadryl

Metoclopramide – can also cause

extrapyramidal reactions

Is Compazine safe and effective?

Prochlorperazine in Children

(Kabbouche, 2001)

The effectiveness and

tolerability of prochloroperazine

in aborting intractable migraine

in children

At 1 hour: 75 % improvement

with 50% headache free

At 3 hours: 95% improvement

with 60% Headache free

Compazine versus Toradol

Prochlorperazine versus ketorolac (Brousseau,

2004)

Double blinded RCT

At 1 hour

84.8% response to prochloroperazine

55.2% response to Ketorolac

93% response when treatments were combined

30% recurrence in 24 hours

Compazine versus Reglan

IV prochlorperazine

versus metoclopramide

(Coppola, 1996)

Double blinded RCT

with placebo

Pain improvement

10mg Compazine 82%

10mg Reglan 46%

Placebo 29%

Compazine versus Reglan (take 2)

Friedman, 2008 – A new RCT of

prochlorperazine versus metoclopramide (at a

higher dose)

Double blind RCT comparing the two agents

Both given with benadryl

Metoclopramide at 20mg (higher dose)

Primary outcome, decreased pain at 1 hour

Pain scores favored prochlorperazine –

though not statistically significant

What if they still have a headache?

If the patient is refractory to Compazine or Reglan +/- Toradol…

(Valproate) Depakote 15-20 mg/kg IV (max of 1 gram) over 10 minutes

You can try a 2nd IV dose within 3 hours of the 1st

If it works they should take the first oral dose within

four hours

Start them on 20mg/kg PO divided bid for 2 weeks

Depakote safety and efficacy

Depakote in migraines is generally well tolerated

(Reiter, 2005)

A retrospective review of 31 adolescents

40% had pain reduction

Potential adverse effects (# pts. in study)

Cold sensation (1)

Dizziness (3)

Nausea (1)

Possible absence seizure (1)

Paresthesia (2)

Tachycardia (2)

Depakote versus Compazine

Prochlorperazine 10mg vs Valproate

500mg (Tanen, 2003)

Randomized prospective double blind study

Valproate less effective in reducing pain and

nausea (p<0.001)

79% of Valproate group needed rescue

medicine

25% of the prochloroperazine group needed

rescue

What about steroids?

Does adding Dexamethasone to standard therapy decrease recurrence? (Singh, 2008)

Meta-analysis of seven trials (742 patients)

Dexamethasone added to standard antimigraine therapy reduces the rate of patients with moderate or severe headache on 24 to 72 hour follow-up

RR = 0.87 (95% CI = 0.80 to 0.95;

ARR = 9.7%

Not studied in pediatric populations

Migraine treatment summary

If you’re going to pick one agent go with Compazine

If you’re going to use two then add Toradol

Reglan is a good alternative, especially if the patient had side effects to Compazine that Benadryl didn’t help

If the first line doesn’t work, then try Depakote

Refer migraine with aura patients to the Neurology headache clinic

If Depakote doesn’t work admit

Admission for migraines

Intractable to ED therapy

Status migrainosus

Chronic severe headache

Analgesic rebound headache

Inpatient options at CCHMC

DHE (5HT1 agonist, synthetic ergot)

Valproate sodium

Magnesium

IV Steroids

What would you do?

Recall that this case was the 15 year old female with pounding frontal headache and nausea that was preceded by transient (<30min) upper extremity weakness and tingling

What do you tell her?

What is your treatment plan?

Does she need any imaging?

A few words about psychogenic headaches

Common features

School avoidance

Malingering with secondary gain

Conversion disorder

History of chronic headaches unresponsive to

various therapies

They come to the ED to “get another opinion”

Don’t dismiss them, allay parents’ fears, and arrange

for appropriate follow up

Not applicable to the acute headache!

The big 5

Take home points about headaches in the pediatric ED

Order a head CT if…

Persistent/duration <6 months and unresponsive to treatment

Abnormal neurologic findings

Awakens from sleep or immediately upon awakening

Signs of elevated ICP

Think brain tumor in patients with AM headaches, worsening

vomiting, abnormal neuro exam

Compazine or Reglan +/- Toradol and IV fluids are the best

treatments for migraines in the ED

Depakote is effective in refractory migraines

It’s hard to tell a migraine with aura from stroke if it is a

new/different headache with aura symptoms lasting >60 minutes

References

Brousseau, D. Treatment of pediatric migraine headaches: A randomized, double-blind trial of prochlorperazine versus ketorolac. Annals of Emergency Medicine, 2004. Volume 43, Issue 2, Pages 256-262.

Coppola, M. Randomized, Placebo-Controlled Evaluation of Prochlorperazine Versus Metoclopramide for Emergency Department Treatment of Migraine Headache. Annals of Emergency Medicine, 1995, Volume 26, Issue 5, Pages 541-546.

Fleisher et al. Textbook of Pediatric Emergency Medicine 5th Ed. 2006 Lippincott Williams & Wilkins.

Friedman BW, Esses D, Solorzano C, et al. A Randomized Controlled Trial of Prochlorperazine Versus Metoclopramide for Treatment of Acute Migraine Ann Emerg Med. 2008;52:399-406

Hachinski VC, Porchawka J, Steele JC. Visual symptoms in the migraine syndrome. Neurol. 1973;23 :570 –579.

Honig PJ, Charney EB. Children with brain tumor headaches: distinguishing features. Am J Dis Child 1982; 136: 121-141.

References

Kabbouche, MA, et al. Tolerability and Effectiveness of Prochlorperazine for Intractable Migraine in Children. PEDIATRICS Vol. 107 No. 4 April 2001, p. e62.

Lewis, DW, Pediatric Migraine. Pediatrics in Review. 2007;28:43-53.

Medina LS, et al. Children with headache: clinical predictors of surgical space-occupying lesions and the role of neuroimaging. Radiology 1997 Mar;202(3):819-24.

Reiter PD, Nickisch J, Merritt G. Efficacy and Tolerability of Intravenous Valproic Acid in Acute Adolescent Migraine. Headache 2005;45:899-903.

Singh, A et al. Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta-analysis and Systematic Review of the Literature. Academic Emergency Medicine. 2008. Volume 15 Issue 12, Pages 1223 - 1233.

Tanen, D. Intravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: A prospective, randomized, double-blind trial. Annals of Emergency Medicine, 2003. Volume 41, Issue 6 , Pages 847-853.

Thanks

Marielle Kabbouche, MD

Selena Hariharan, MD