Headaches in the Pediatric Emergency Dept

Transcription

1 Headaches in Children February 23, 2011 Jinny Tavee, MD Associate Professor Neuromuscular Center Cleveland Clinic Foundation Cleveland, OH 1 Headaches in the Pediatric Emergency Dept Burton Gutierrez Kan Lewis Infection Viral 39% 31% 28.5% 39% Sinus 16% 9% Other 5% 2.3% 9% Viral meningitis 5% 2.3% 9% Migraine 16% 21% 8.5% 18% Tension 5% 29% 1.5% Trauma 7% 20% 1.3% Tumor 4% 15% 1.5% 26% 2.6% Shunt / hydro 11.5% 2% Seizure 3% 1.3% Other 7% 15% 13% 7% Modified with permission Rothner A,

2 Migraine Prevalence in Children Ages 2 7: Prevalence: 3 % Boys > Girls Ages 7 11: Prevalence: 4 11% Boys = Girls Ages 11+: Prevalence: 8 23% Boys < Girls Eiland etal, Ped Drugs 2010;12: Migraine: Treatment options OTC medications: Acetominophen (paracetamol) NSAIDs Antihistamines AAN Recommendations: Nasal sumatriptan safe and may be considered for acute treatment in US (approved in Europe for children >12) No benefit with oral sumatriptan vs placebo Almotriptan is only FDA approved triptan in US Contraindicated in children with congenital heart disease 2 reported cases of MI in the literature in children Zolmitriptan nasal spray and oral rizatriptan show some benefit but would be OFF LABEL Lewis etal, Neurol 2004;63: Eiland etal, Ped Drugs 2010;12:

3 Dr. Rothner s Rescue Cocktail 1. Cool dark room with cold compress 2. Oral dissolving ondansetron 4-8mg for N/V 3. Diphenhydramine mg for sedation 4. NSAID (ibuprofen, naproxen) 10mg/kg 5. If HA severe or migrainous, add triptan (if no contraindications) 6. If HA still present 2hrs later, repeat diphendyramine and triptan with addition of 15mg/kg of acetaminophen 5 Migraine: Prevention Consider if HA frequency 3-4/month or significantly affects quality of life Tricyclic clic antidepressants, antiepileptics, Ca channel blockers, beta blockers, antiserotonergic agents, and botox may be considered NONE ARE FDA APPROVED Propranolol approved in Finland for patients

4 Chronic Daily Headaches Definition Daily or near daily headaches Frequent Daily / Intermittent 24/7 Non-progressive Present for 3 months or longer At least 15 days per month More than 4 hours per day Secondary etiologies have been excluded Gladstein etal Sem Ped Neur 2010; Chronic Daily Headaches Varieties Transformed / Chronic migraine Chronic tension type headaches New onset daily persistent headaches Hemicrania continua Others: Post-traumatic Post-infectious Psychogenic Medication overuse 8 4

5 New Onset Daily Persistent HA A daily, unremitting headache from onset No prior headache h history is noted Bilateral, moderate, pressing pain Antecedents 40%: viral illness, trauma No underlying etiology is found MRI brain Gladstein etal Sem Ped Neur 2010; Chronic Daily Headache Complex Disorder Requiring Multifaceted Approach to Management Lifestyle modifications Behavioral therapy Dietary Modifications Chronic Daily Headache Management Trigger management Behavioral therapy Pharmacologic therapy Education, support, managing expectations, and close follow-up Alternative Approaches Modified from Dodick DW. N Engl J Med. 2006;354(2): Rothner AD,

6 Chronic Daily Headache Alternative Treatments 1. Magnesium, Riboflavin, i Co-enzyme q10, Butterbur 2. Counseling, Cognitive Behavioral Therapy, Biofeedback 3. Physical Therapy, Massage, Acupuncture, Yoga 4. Botox, Trigger Point Injections 5. Inpatient Rehabilitation 11 Headaches: Red flag symptoms New, severe, or worst HA ever Wakes the child up in the middle of the night Fever, stiff neck Recent trauma Worse with exertion or straining Persistent projectile vomiting Seizures 12 6

7 Headache: Red flags on the exam Large head Bruits Neurocutaneous abnormalities Papilledema Abnormal eye movements Fever Altered mental status Focal motor or sensory abnormalities Asymmetrical reflexes Ataxia Modified with permission Rothner A,

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