Pediatric Headaches: Is It Their Eyes? Catherine McDaniel, OD, MS, FAAO

Transcription

1 Pediatric Headaches: Is It Their Eyes? Catherine McDaniel, OD, MS, FAAO Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.

2 Outline Prevalence of pediatric HA Types of HA HA history When to image? Ocular causes of HA Eye/vision evaluation HA management

3 Prevalence 5% of school-aged children complain of HA Adolescence: 8% girls, 5% boys report migraine 27% girls, 20% boys report frequent or severe HA Adults: 15% women, 8% men report migraine 80% women, 60% men report HA Lateef TM, Merikangas KR, He J, et al. Headache in a national sample of American children: prevalence and comorbidity. J Child Neurol. 2009;24(5): Abu-Arafeh I, Razak S, Sivaraman B, Graham C. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Dev Med Child Neurol. 2010;52(12):

4 Prevalence Most common cause of childhood HA presenting to ED: Viral illness (39-57%) Migraine (16-18%) Primary care providers most commonly provide management for acute recurrent and chronic HA

5 Types of Pediatric Headache Primary HA Tension Migraine Secondary HA

6 Primary Headache Tension Can last 30 minutes to 7 days Characteristics Bilateral location Pressing or tightening quality Band-like pressure around head Mild to moderate intensity Not triggered/worsened by routine physical activity No nausea or vomiting

7 Primary Headache Migraine Can last 2 hours to 3 days Characteristics: Typically unilateral Fronto-temporal Pulsing quality Moderate to severe intensity Aggravated by routine physical activity May include: Nausea and/or vomiting Photophobia and/or phonophobia

8 Migraine Classification Migraine without aura (G43.0) Migraine with aura (G43.1) Migraine with typical aura (with or without HA) Migraine with brainstem aura Hemiplegic migraine (G43.4) Retinal migraine (G43.B) Chronic migraine (G43.7) Probable migraine (with or without aura)

9 Migraine Classification Complications of migraine Status migrainosus Migraine is typical of previous attacks except for duration Unremitting for more than 72 hours (single attack, not repeated attacks) Severe intensity Headache urgency that may require hospitalization Migrainous infarction (stroke) Case reports Aura-triggered seizure

10 Migraine Classification Episodic syndromes that may be associated with migraine Cyclical vomiting (G43.A) Benign paroxysmal vertigo (H81.1) Benign paroxysmal torticollis

11 Secondary Headache Etiologies Organic Neoplasia Altered CSF pressure Structural (ie Chiari malformation) AV malformation Hemorrhage

12 Secondary Headache Etiologies Post-traumatic Onset within 2 weeks of closed head injury 7% of kids with head trauma report post-traumatic HA Vascular disorders HTN Vascular dissection Obesity Ehlers-Danlos, Marfan syndrome, chiropractic manipulation, sports injury Chronic tension-type HA Substance or its withdraw Caffeine, alcohol, carbon monoxide, solvents, iron-deficiency Sleep disturbance Sleep apnea, co-sleeping with parents

13 Secondary Headache Etiologies Infections Rhinosinusitus Frontal HA Pain in face, ears to teeth Viral URI Lyme disease Teeth, Temporomandibular Joint Disorder Bruxism or other abnormal jaw behaviors Dental or oral disease Mood disorders Up to 80% of kids with HA have comorbid psychiatric disorders Ocular!! Anxiety or depression is most common

14 Outline Prevalence of pediatric HA Types of HA HA history When to image? Ocular causes of HA Eye/vision evaluation HA management

15 Headache History: Temporal Pattern Lewis, DW. Headaches in Children and Adolescents. American Family Physician. 2002;65:625-32,635-5.

16 Temporal Pattern Chronic progressive Gradual increase in frequency or severity Most ominous pattern Strongly suggestive of organic pathology Lewis, DW. Headaches in Children and Adolescents. American Family Physician. 2002;65:625-32,635-5.

17 Temporal Pattern Chronic non-progressive Chronic daily Occurs in % adolescents HA lasts 4+ hours Occur 15 or more times per month Must look for underlying medical or psychological cause

18 Headache History Blume, HK. Childhood Headache: A Brief Review. Pediatric Ann. 2017;46(4):e155-e165.

19 Medical History Full ROS Psychiatric Other conditions associated with HA: Hypoglycemia, Chronic renal failure, mitochondrial disorders, thyroid dysfunction, anemia, sickle cell disease, systemic lupus erythematosus Family history HA often run in families Social history School Social media Friends Drugs/alcohol Abuse

20 History Other neurologic signs/symptoms Orientation Time, person, place Mini-mental state exam (MMSE) Coordination/gait Ataxia Abnormal eye movements Seizures

21 Headache Diary Log each HA: Timing Location Activities Triggers Relief Associated symptoms Apps: iheadache Headache Buddy

22 When to image? American Academy of Neurology recommendations: On a routine basis, neuroimaging is not indicated in children with recurrent HA and normal neurologic exam Can be considered in children with abnormal neurologic exam, the coexistence of seizures, or both Can be considered in children where there are historical data to suggest recent onset of severe HA, change in type of HA or associated features suggesting neurologic dysfunction

23 When to image? Study of MRI in children with headaches 478 patients with HA 407 (85%) imaged with MRI 5 patients had tumors (1.2%) Gurkas et al. Brain magnetic resonance imaging findings in children with headache. Arch Argent Pediatr 2017; 115(6):e349-e355.

24 When to image? Study of pediatric brain neoplasm vs. primary HA What findings put you most at risk for being in the neoplasm group? Neurologic signs (10.3x greater chance) Seizure (10.8x) Vomiting (6.6x) Headache (0.5x)

25 Ocular Causes Refractive error Accommodative Binocular vision Ocular health

26 Ocular Causes Refractive error: uncorrected or under-corrected Astigmatism Hyperopia Low amounts Latent What s age normal? Don t forget cycloplegia! Mutti DO, et al. Accommodation, acuity and their relationship to emmetropization in infants. Optometry and Vision Science 2009; 86(6),

27 Accommodation Insufficiency Infacility Spasm

28 Accommodative Conditions Accommodative insufficiency Clinical signs: Reduced amplitudes of accommodation High lag on MEM Trouble with minus on BAF and MAF

29 Accommodative Conditions Accommodative infacility Clinical signs: Normal accommodative amplitudes Normal lag on MEM Trouble with plus and minus on BAF and MAF

30 Accommodative Conditions Accommodative spasm Clinical signs: Eating minus on refraction Significantly more plus found on cycloplegic refraction Lead on MEM Trouble with plus on BAF and MAF

31 Binocular Vision Convergence Divergence Both!

32 Binocular Vision Conditions Convergence insufficiency Clinical signs: Cover test: XP > near Reduced BO vergence ranges at near Receded NPC

33 Binocular Vision Conditions Convergence Excess Clinical signs: Cover test: EP > near» Make sure to use good acc m target!! Reduced BI vergence ranges at near High lag on MEM Trouble with minus on BAF

34 Binocular Vision Conditions Divergence insufficiency Clinical signs: Cover test: EP > distance Reduced BI vergence ranges at distance

35 Binocular Vision Conditions Divergence Excess Clinical signs: Cover test: XP > distance Note: if noticing IXT at distance, check for a vertical Reduced BO vergence ranges at distance

36 Binocular Vision Conditions Fusional vergence dysfunction Clinical signs: Cover test: Ortho or low phoria at distance and/or near Reduced BO and BI fusional vergence ranges

37 Vertical phoria Clinical signs: Vertical misalignment on: Cover test Maddox rod Associated phoria Asymmetric vertical vergence ranges Treatment: Best refractive correction! Added plus at near

38 Ocular Health Papilledema Bilateral swollen nerve due to increased intracranial pressure Always evaluate nerve on HA patient Increased IOP Inflammation Uveitis

39 Vision / Ocular Evaluation Refractive error EOM Pupils Visual fields Binocular vision Accommodation Ocular health

40 Refractive error evaluation Don t underestimate the power of appropriate refractive correction! Equalize accommodation Retinoscopy vs. autorefraction Cycloplegia ** Do not test BV until best correction in place! **

41 Extraocular motility evaluation Watch carefully Ask about pain and diplopia Look for: Smooth movements Full extent of movement Nystagmus

42 Visual field evaluation When child is old enough, check automated VF! Screening field: 8+ years old Threshold VF: older? It all depends on the sophistication of the child HA are neurologic condition and VF is standard of care

43 Pupil evalution Look for: Pathologic anisocoria Afferent pupillary defect

44 Binocular Vision Ocular alignment NPC Vergence ranges

45 Ocular alignment Free space vs. phoropter Cover test Fixation target Distance: 20/30 single letter (or a line above their BCVA) Near: 20/30 single letter Stress target clarity Prism neutralization Make sure you get a sustained reversal For strabismus, note: Frequency: constant or intermittent Laterality: unilateral or alternating Direction: eso, exo, hypo, hyper

46 Ocular alignment Maddox Rod Loose prism neutralization Variable prism Modified Thorington Remember: Maddox rod always goes over OD Red over Right

47 Near Point of Convergence 20/30 vertical row of letters Follow target in towards nose until breaks or eye turns out Repeated 3 times to look for fatigue Normal value < 6cm

48 Vergences Vergence ranges Prism bar Sheard s criterion Compensating fusional vergence range should be twice phoria value Normal values: Distance: Near: BI: x/7/4 BO: 9/19/10 BI: 13/21/13 BO: 17/21/11

49 Accommodation Amplitude Facility Accuracy

50 Accommodation Accommodative Amplitude 20/30 vertical row of letters Target moved in towards eye until no longer clear Performed monocularly and binocularly Repeated 3 times in each eye to look for fatigue Average: (age) Minimum: (age)

51 Accommodation Accommodative Facility binocular, monocular +/-2.00 flippers 20/30 row or Word Rock card Timed 1 minute Norms: 13-30yo 10cpm binocular, 11cpm monocular Saying clear 8-12yo 5cpm binocular, 7cpm monocular Calling out letters

52 Accommodation Accommodative Accuracy MEM: retinoscope, MEM cards Normal: D

53 Ocular Health Anterior segment Posterior segment

54 Headache management Ocular causes: Refractive Glasses BV or accommodative Added lenses Prism Vision therapy Ocular health Medical management

55 Headache management Four domains of HA treatment: Lifestyle modification Abortive therapy Preventative treatment Complementary therapies

56 Headache management Lifestyle modification Blume, HK. Childhood Headache: A Brief Review. Pediatric Ann. 2017;46(4):e155-e165.

57 Headache management Abortive therapy Medication for acute HA Blume, HK. Childhood Headache: A Brief Review. Pediatric Ann. 2017;46(4):e155-e165.

58 Headache management Preventative treatment Medication for prevention of HA Blume, HK. Childhood Headache: A Brief Review. Pediatric Ann. 2017;46(4):e155-e165.

59 Headache management Preventative treatment Medication for prevention of HA Nerve block Typically of greater occipital nerve Lidocaine injection

60 Headache management Complementary therapies Yoga Acupuncture Hypnosis Cognitive-behavioral therapy

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