Headache in Childhood (Case 4)

Chapter 32 Headache in Childhood (Case 4)



Marcy E. Yonker, MD, FAHS




Case


An 8-year-old child with episodic headaches




Differential Diagnosis









Migraine Tension-type headache Acute sinusitis


Speaking Intelligently


When I evaluate a child with headache, I first determine the pattern of the headaches (episodic, daily with headache-free periods, daily without headache-free periods), and the tempo of the complaint (stable or progressive). If a child has progressively worsening headaches, I am more concerned about a serious cause. I inquire about the specific headache symptoms: location, nature, severity, duration, associated symptoms, exacerbating and ameliorating features to further refine whether this is a primary headache disorder such as migraine or tension-type headache, or if it may be secondary to a neurologic problem causing increased intracranial pressure like a brain tumor, venous sinus thrombosis, or pseudotumor cerebri. Most headache diagnoses are made clinically by taking a thorough history and performing complete medical and neurologic examinations. I rarely obtain an imaging study in a patient with episodic headaches and a normal examination.



Patient Care



Clinical Thinking



• Healthy patients with episodic headaches and normal examinations rarely have a serious neurologic problem.

• Migraines in children are moderate to severe headaches that cause disability and are associated with light and sound avoidance and/or nausea/vomiting, and are usually relieved by sleep. Duration may be as short as 1 hour. Patients with infrequent migraines need only as-needed therapy. Patients with frequent (more than three to four disabling headaches per month) need both preventive and abortive therapy.

• Children with progressive headaches without significant migrainous features, or with concerning neurologic symptoms/signs such as intellectual deterioration, gait ataxia, double vision or seizures, need urgent evaluation and imaging.

• Sinus headaches are caused by acute obstruction of the osteomeatal complex and are associated with nasal discharge, postnasal drip and/or chronic cough. Chronic sinus disease that does not obstruct the drainage of nasal secretions usually does not cause headache (see Chapter 36, Fever).


History



• Note onset of headaches and any inciting incidents (head trauma, illness, change in medications such as oral contraceptives, stressful events). Emergent evaluation and neuroimaging may be required for head trauma to exclude intracranial hemorrhage or concussion syndrome (see Chapter 86, Trauma).

• Note nature of headaches: gradual versus sudden onset of pain, description of pain, severity of pain, location, exacerbating/ameliorating features.

• Note presence of migraine-associated symptoms such as light sensitivity, sound sensitivity, nausea, vomiting, exacerbation by or avoidance of routine physical activities.

• Note presence of migraine aura preceding or during headache, such as flashing lights, black spots, vertigo, or paresthesias, that clears within 1 hour.

• Headaches that awaken a patient from sleep or reach maximal intensity abruptly are concerning for a headache caused by an intracranial process such as increased intracranial pressure or intracranial bleed.

• Headache, stiff neck, vomiting, and/or change in mental status is concerning for meningitis (see Chapter 49, Meningitis).


Physical Examination



• Vital signs: Systolic hypertension may be secondary to ongoing headache pain or increased intracranial pressure. Obesity is associated with pseudotumor cerebri.

• A thorough general examination including inspection of the tympanic membranes and oropharynx and palpation of the face to exclude otitis media, mastoiditis, and sinusitis

• A complete neurologic examination including visualization of the optic discs and observation of venous pulsations to help rule out increased intracranial pressure is mandatory.

• Neurologic examination should exclude any focal neurologic abnormalities such as focal weakness, dysmetria, ataxia, or focal sensory loss.
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  4. Note Writing

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Headache in Childhood (Case 4)

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