Catrinel Iliescu Pediatric Neurology Clinic Al Obregia Clinical Hospital Bucharest

WHY A DISCUSSION ABOUT HEADACHE?

Headache is a frequent reason for consultation even

in childhood

When repeated, it can affect the QoL of children

depending also on etiology

WHAT IS CAUSING HEADACHE?

Intracranial pain-sensitive structures
Cerebral and dural arteries Intracranial venous sinuses and their large tributaries Cranial nerves (II, III, V, IX, X) Parts of the dura at the base of the brain

Extracranial pain-sensitive structures

Extracranial arteries

Cervical roots
Delicate structures of the eye, ear, nasal cavities, sinuses Skin, subcutaneous tissue, muscles, periosteum of the skull

WHAT IS THE MECHANISM?

Vasodilatation Inflamation Traction Sustained muscular contraction
Supratentorial structures of the head (CN V) Infratentorial structures (upper cervical roots) referred pain to anterior two-thirds referred pain to the neck and occiput

WHAT STRUCTURES ARE INSENSITIVE TO PAIN?

Brain parenchyma Ependyma and choroid plexuses Much of the pia-arachnoid and dura over the

convexity of the brain

Bony skull

CLASSIFICATION
Etiological criteria

Temporal criteria

ETIOLOGICAL CRITERIA
PRIMARY HEADACHE
Migraine
Paroxysmal unilateral headaches Cluster headache Tension-type headache

SECONDARY HEADACHE
Infections of the CNS
Intracranial haemorrhages Increased intracranial pressure, varied etiologies

TEMPORAL CRITERIA
ACUTE HEADACHE
ACUTE RECURRENT HEADACHE

CHRONIC NON PROGRESSIVE HEADACHE

CHRONIC PROGRESSIVE HEADACHE MIXED

MANAGEMENT OF THE CHILD WITH HEADACHE

HISTORY
CLINICAL EXAMINATION

COMPLEMENTARY EVALUATIONS

DIAGNOSIS TREATMENT

MANAGEMENT OF THE CHILD WITH HEADACHE THE HISTORY

The key of a correct diagnosis Questions for the child + parents
Onset (abrupt, slowly progressive..) Location

Type

Intensity Duration Frequency

Relieving factors

Precipitating/ aggravating factors FAMILY HISTORY

Associated signs (autonomic, neurological, others)

MANAGEMENT OF THE CHILD WITH HEADACHE THE CLINICAL EXAMINATION

Very important also General state, febrile / not / meningeal signs! BP Palpation of facial sinuses Neurological
Consciousness Cranial nerves papilloedema

Gait, fine movements / Coordination Reflexes (DTR, pathological reflexes) Sensory testing

MANAGEMENT OF THE CHILD WITH HEADACHE COMPLEMENTARY EVALUATION

Always related to the history and clinical examination!
Imaging EEG LP

Routine biological screening

Other referrals ophtalmology, ENT, psychiatrist

RED FLAGS
Thunder-clap headache (severe headache of sudden onset) Headache
with abnormal neurological examination with fever and meningeal signs! with seizures without fever, with meningeal signs

Short history of headache

Persistently lateralized headache Progressive course of headache

Occipital headache in a child <10y Headache that awakens the child during the night Abnormal increasing of head circumference Small age Declining of school performances, personality changes

ACUTE HEADACHE = recent onset of headache, no previous history of headaches

ETIOLOGICAL POSSIBILITIES
Febrile illness
Infections of CNS Cranial trauma

Intracranial haemorrhage
Post-punctional headache Exertional headache

After a first seizure

First attack of migraine Localized

ACUTE RECURRENT HEADACHE = repeated attacks of headache, no signs/symptoms between attacks

Migraine the most frequent cause of recurrent headache
Hereditary condition
Recurrent headache Usually unilateral and throbbing

Associated with autonomic signs Sometimes with neurological signs

Typically relieved by sleep in childhood

CLASSIFICATION OF MIGRAINE
Migraine without aura (common migraine)

Migraine with aura

Migraine variants

EPIDEMIOLOGY OF MIGRAINE
Migraine is among the most prevalent neurological

conditions
Approx 7% of children 5-15 y do have migraine Approx 15% of all people will have migraine Most adults will have their first migraine < 20 y of age

(20% before age of 5y!)

Family history is + in approx 60-80% of cases

MIGRAINE PATHOGENESIS
Mechanisms proposed:
Neurovascular Vascular Neuronal Neurotransmitter

Channelopathy
Mithocondrial disfunction

MIGRAINE WITHOUT AURA (60-85% of cases)

5 or more attacks of headaches Duration 1-48 h
Headache has at least 2 of the following characteristics:
Bilateral (frontal or temporal) or unilateral location Pulsatile quality Moderate to severe intensity Aggravated by routine physical activity

During the headache, 1 of the following occurs:

Nausea or vomiting Hyperestesia (photophobia and phonophobia)

MIGRAINE WITH AURA (15% of cases)

At least 2 attacks fulfilling the following criteria: At least 3 of the following characteristics:
One or more fully reversible aura symptom indicating focal cortical

and/or brainstem dysfunction

At least one aura developing gradually > 4 min or >=2 aura symptoms

developing in succession
No auras > 60 min

Headache following no more than 60 minutes after the aura

Headache will have the characteristics described before

MIGRAINE VARIANTS- small children, episodic events, no headache

Benign paroxysmal vertigo

Abdominal migraine

Ciclic vomiting

CHRONIC UNPROGRESSIVE HEADACHE = tension-type headache

Persistent headache with no associated autonomic

symptoms, no neurological signs

Mild, diffuse, does not interact with routine activities

Most often related to psychological factors (tension)

Except psychological evaluation no other complementary

evaluation is needed (some exceptions do exist)

CHRONIC PROGRESSIVE HEADACHE RED FLAG! usually symptomatic

Initially episodic headache but short after

becomes persistent and progressive

Can awake a child from sleep (toward morning) / is evident

immediately after awakening

Often vomiting is associated, can relieve headache Aggravated by straining, coughing, sneezing Mechanism: traction, infiltration Clinical examination: usually (?) abnormal if rigurous

(including search for papilloedema); tilted head; OFC

MIXED HEADACHE
Most often a pattern of episodic headache transformed

into a chronic unprogressive one

Psychological factors contribute

Analgezics overuse

Transformed migraine (chronic migraine)

TREATMENT
Symptomatic analgetics

Etiopathogenic:
Antibiotics if bacterial meningitis, cerebral abcess

Antivirals if viral (herpetic) encephalitis

Surgery if acute epidural/ subdural haematoma folowing BT Liquids, salt, caffeine if postpunctional

Surgery if intracranial mass / hydrocephaly

Antimigraine treatments Antidepressants if needed in tension type headache

MIGRAINE MANAGEMENT
Acute treatment:
Analgetics
Antiemetics Triptans Ergot derivates

Chronic prophylaxy frequent attacks, complicated

Propranolol Valproic acid, topiramate amytriptiline

long-term treatments (mth)

MIGRAINE MANAGEMENT
Behavioral management:

Avoidance of analgetic over-use Regular sleep (not too long, too short) Regular meals, breakfast important for children During a headache

Avoidance of stimuli Encouraging sleep the most powerful treatment for childhood migraine

CONCLUSION
Headache is frequent in childhood

Recurrent headache is often a migraine

Symptomatic headache in childhood is associated with special

patterns, which should be recognized, and usually with an abnormal neurological examination (exceptions do exist!)

The treatment & prognosis depend on etiology and on the

mechanism (precise diagnosis) history and clinical examination are the most important tools for a correct diagnostic