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HEADACHE IN KIDS
Types:
Primary
Secondary
Headache Syndromes
Evaluation
Management
Pharmacologic
Nonpharmacologic
Intracerebral arteries
Cervical nerves
February 1, 2012
Acute Localized
Sinusitis
Otitis
Ocular abnormality
Dental disease
Trauma
Occipital Neuralgia
TMJ disorder
Recurrent
Vascular Disease
Intoxication
MELAS
Postseizure
Hypoglycemia
Exertion
Chronic Progressive
Tumor
Pseudotumor
Brain abscess
Subdural hematoma
Hydrocephalus
PRIMARY HEADACHES
Migraine
Tension-type
Cluster
SECONDARY HEADACHES
C
Congenital anomalies (HCP, Arnold-Chiari)
I
Infections (meningitis, abscess)
T
Toxin (cocaine, amphetamine)
T
Trauma (subdural, epidural)
E
Endocrine (hypoglycemia)
N
Neoplasm (brain tumor, leukemia)
D
Degenerative disorder (Alexanders
disease)
V
Vascular (aneurysm, AVM, coagulation
disorder)
M
Metabolic (hypoxia, dehydration, fever)
Secondary Headache
(Temporal Presentation)
Acute Generalized
Systemic infection
CNS infection
Toxins(lead,CO)
Postseizure
Electrolyte imbalance
Hypertension
Hypoglycemia
PostLP
Trauma
Embolism
Vascular thrombosis
Hemorrhage
Collagen disease
Exertion
mcps
Shunt Malfunction
Mood changes
Irritability
Euphoria
Increased thirst
Increased urination
Fluid retention
Yawning, sighing
The headache
Gradual onset
Diarrhea
Pallor
Phonophobia/Photophobia
Desire to sleep
Cool extremities
Periorbital discoloration
Goose flesh
Syncope
Miscellaneous
Motion sickness
Sleep walking
Migraine Auras
Distortion or hallucinations
Micropsia
Macropsia
Matamorphopsia
Teleopsia
central scotomas
Spotty scotomas
Hemianopia
mcps
Response to treatment
Aura
Past hx of headache
Trauma
Associated symptoms/Neurologic
symptoms
Vital signs
Funduscopic examination
Cardiopulmonary examination
Skin rashes, petechiae, ecchymosis, needle tracts
Hepatosplenomegaly
Neurologic exam
Imaging for the Evaluation of Headache
High priority
Acute headache
Thunderclap headache
Presence of VP shunt
Moderate priority
Meningeal signs
31%
Fasheh Y. et.al.,
Pediatrics, 1999
57%
(39%)
(9%)
(9%)
18%
9%
2.6%
1.3%
1.3%
1.3%
1.3%
Lewis DW et.al.,
Headache, 2000
Combination Analgesic
Fioricet
Butalbital+Acetaminophen+Caffeine
Esgicplus
Axocet
Ergotamine (dihydroergotamine)
Antiemetics
Opioid analgesic
Preventive Migraine Therapy
10mg/kg
Pratt-Cheney JL et.al.,
Pediatric Emergency Care, 1997
Infection
Tension
Migraine
Non-specific
Naproxen
2%
Agent
Cyproheptadine
HS
Propranolol
BID
Tricyclics
Amitriptyline
10mg HS
Nortriptyline
10mg HS
Divalproex sodium
125mg QD
Initial Dosage
2 mg BID or 4 mg
1mg/kg up to 10mg
0.25mg-0.5mg/kg to
0.25mg-0.5mg/kg to
10mg/kg to
Drug
Ergotamine
Dihydroergotamine
Isometheptene
Triptans
Chlorpromazine,promethazine
Metoclopromide
Lidocaine (4%)
Mechanisms
Vasoconstrictor
Vasoconstrictor
Vasoconstrictor
Serotonin agonists
Antiemetic
Local anesthetic
Simple analgesics
Dosage
Acetaminophen
15mg/kg
Ibuprofen
mcps
1010mg/kg
Migraine Triggers
FOODS
Ripened cheeses
Chocolate
MSG
Bananas
Pizza
Caffeine
Food dyes
ODORS
Perfume
Gasoline
STRESSES
School work
Relationships
Disruption of lifestyle
Feeling bummed out or sad all the time
SEIZURES
Seizure
Brain tumor
CVA
Metabolic disorders
Alcoholism
Why Classify?
Definition
Seizure transient manifestation of abnormal
hypersynchronous discharges of cortical
neurons
Cellular level
Sodium channels
Calcium channels
Potassium channels
Synaptic level
Glutamate (excitatory)
GABA
(inhibitory)
Sodium currents/channels
Infant
Genetic
(0-2 years old)
Hypoxia
Congenital Anomalies
Child
(2-12 years old)
Adolescent
(12-18 years old)
use/withdrawal
mcps
Head trauma
Acute Infection
Head trauma
Drug and alcohol
I. Partial seizure
A. Simple partial seizure (consciousness not impaired)
B. Complex partial seizure (with impairment of
consciousness)
C. Partial secondarily generalized
II. Generalized seizures
(bilaterally symmetrical and without local onset)
A. Absence seizures
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic-clonic seizures
F. Atonic seizures (astatic)
III. Unclassified epileptic seizures
(inadequate or incomplete data)
The ILAE Classification of Epilepsies and Epilepsy
Syndromes Shorvon, 2000
Simple Partial Seizure and Complex Partial Seizure
Impaired Consciousness
Responsiveness
Awareness
PARTIAL SEIZURE
Abnormal flow of electrical discharge from a specific or
single focus
Simple Partial Seizures
Versive
Postural
Illusions (macropsia)
mcps
Automatisms
Ambulatory automatisms
Verbal automatisms
Partial
Secondarily Generalized
Simple evolving to GTC
Complex evolving to GTC
Simple evolving to complex evolving to GTC
DO:
Lay the patient on the floor.
Place something soft and flat under the head.
Loosen tight clothing around the neck.
Turn the head gently toward one side to prevent
choking.
Remove all sharp objects out of the way.
Time the seizure.
Reassure the patient as he regains
consciousness.
Dont restrain.
First seizure
Presence of injuries
Types of seizures
Frequency of seizures
Severity of seizures
Timing of seizures
Precipitation of seizures
Control of Seizures
Tolerability
Pharmacokinetic properties
Patient Characteristics
Drug interactions
Cost
1910 PHENOBARBITAL
- initially was used to induce sleep
- later found to have anti-seizure properties
1940 PHENYTOIN
- found to be effective in the treatment of
epilepsy major first line AED for partial and
secondarily generalized seizure
mcps
1968 CARBAMAZEPINE
- initially approved for the treatment of trigeminal
neuralgia
- 1974 later approved for partial seizures
1958 ETHOSUXIMIDE
- first choice for Absence seizure without
generalized tonic-clonic seizures
Pharmacologic Properties
Phenobarbital
Mechanism of Action
Metabolism Liver
Main advantages
Highly effective
Cheap drug
OD or BID dosing
Hyperactivity (behavioral)
Effect on IQ (cognitive)
Sedation
Phenytoin
Main advantages
Mechanism of action
Metabolism Liver
Main disadvantages
Carbamazepine
generalized seizure
Initially used for Trigeminal Neuralgia
Highly effective and well-tolerated
Mechanism of Action
Valproate
Main advantages
Mechanism of action
Main disadvantages
Mechanism of Action
Metabolism Liver
Main disadvantages
Cognitive effects
Gabapentin
Main advantages
Main disadvantages
Seizure exacerbation
Lamotrigine
Main advantages
well-tolerated
Mechanism of action
Metabolism Liver
Main disadvantages
Oxcarbazepine
Main advantages
mcps
Topiramate
Main indications
Mechanisms of action
Side effects
Dizziness
Paresthesias
Weight loss
Tremors
Depression
Amnesia
Hyperactivity
Mental dullness
Irritability