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Headache in children and adolescents

Headache in children and adolescents. Rachel Hering–Hanit Headache Clinic, Meir Hospital, Kfar Saba Sackler Faculty of Medicine, Tel Aviv University. Epidemiology. Infrequent headaches: at 7y - 37-51% at 15y - 57-82% Frequent headaches: at 7y - 2.5%

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Headache in children and adolescents

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  1. Headache in children and adolescents Rachel Hering–Hanit Headache Clinic, Meir Hospital, Kfar Saba Sackler Faculty of Medicine, Tel Aviv University

  2. Epidemiology Infrequent headaches: at 7y - 37-51% at 15y - 57-82% Frequent headaches: at 7y - 2.5% at 15y – 15.7%

  3. Evaluation Medical history Physical examination Neurological examination > 98% of children with brain tumors have objective neurologic findings

  4. Diagnostic testing Routine laboratory CSF examination EEG Neuroimaging: CT, MR

  5. EEG1,148 children with recurrent headache(slowing, spike&sharp, other)

  6. EEG - Conclusions EEG is not recommended EEG: Normal or nonspecific abnormalities No differences between migraine/nonmig

  7. Neuroimaging605/1,275 children with recurrent headache 116 CT, 483 MR, both 75 Abnormalities: 97 (16%) 79 incidental (Chiari, arachnoid cyst, cavum septi) 18 (3%) surgically treatable lesion 4 pituitary adenoma (spontan.) 14 tumors

  8. NeuroimagingConclusions Surgical treatment - 2.3% All had neurol. abnormalities on exam. No patient with a normal neurol. Exam. had a lesion that required surgical treatment

  9. Neuroimaging Recommendations Not indicated on a routine basis Considered: 1. abnormal neurological exam 2. history of - recent onset change in type associated features that suggest neurologic dysfunction

  10. Indications for neuroimaging

  11. Clues to organic brain lesion 1. Severe headache of recent onset 2. Chronic & progressive 3. Localized pain 4. Wakes child at night 5. Early morning & increase in severity 6. Associated neurological symptoms & signs

  12. Headache classification Acute headache Acute-recurrent headache Chronic-progressive headache Chronic-nonprogressive headache (chronic-daily headache)

  13. Acute headache URI Sinusitis Pharyngitis Meningitis Migraine Hypertension Substance abuse

  14. Acute headache ER studies All serious conditions (ICH, SOL) – objective neurological findings (alteration in consciousness, nuchal rigidity, papilledema, abnormal eye movements, ataxia, hemiparesis)

  15. Acute-recurrent headache Migraine Tension Benign exertional Paroxysmal hemicrania Cluster

  16. Chronic-progressive headache

  17. Chronic-nonprogressive chronic-daily headache Psychological Conversion Depression Malingering Stress

  18. Management of specific headaches in children

  19. Acute-recurrent headache

  20. Childhood migraine Without aura At least 5 attacks fulfilling: 1. Lasting 1-48 h 2. Headache as at least 2 of the following: bilateral or unilateral pulsatin quality moderate to severe aggravated by activity 3. During attacks at least 1 of the following: nausea/vomiting photophobia/phonophobia

  21. Childhood migraine With aura At least 2 attacks fulfilling 3 of the following: 1. > 1 fully reversible aura symptom 2. 1 lasting 4 min. or > 2 in succession 3. no aura lasting > 60 min. 4. headache follows < 60 min

  22. Characteristic unique to childhood migraine Male predominance Headache is less often unilateral Shorter episodes: min to several h History of motion sickness (45%)

  23. Migraine Prevalence

  24. Long-term prognosis of childhood migraine

  25. Migraine variant Cyclic vomiting Cyclic abdominal pain Benign paroxysmal vertigo Confusional state: acute confusion hyperactivity disorientation unresponsiveness memory disturbances

  26. Treatment of childhood migraine General measures: reassure remove triggers regulate lifestyle behavior therapy Pharmacologic mamagement: acute medication preventive medication

  27. Diet & migraine Cheese Chocolate Citrus fruit, figs, peas, peanuts, olives, tomatoes Hot dogs, cured meat Wine, beer Coffee, tea, cola Asian, frozen, snack food (pizza), canned soup Food dyes, additives Artificial sweeteners Fatty & fried foods

  28. Acute treatment Simple anagesic: acetaminophen, dipyrone, aspirin Combination NSAID’S: ibuprofen, naproxen 5-HT1 receptor agonists: sumatriptan zolmitriptan rizatriptan eletriptan

  29. Prophylaxis Antihistamine (cyproheptadine) Antidepressants (amitriptyline) Beta-blockers (propranolol) Anticonvulsants (valproate, topiramate)

  30. Cluster Headache Uncommon in <10 y olds Intense, non-throbbing peri-orbital pain Short-lasting Unilateral conjuctival injection, tearing and rhinorrhoea Attacks persist for weeks to months- stop-recur months later

  31. CH Treatment Acute: oxygen triptan Preventive: steroids Ca-antagonists anti-convulsants lithium

  32. Chronic daily headache

  33. Analgesic induced headache Abuse is common in adults (10-15%) Medication-induced headache First report in children:1998 (UK, USA) A. H. Cohen, Z. Horev J Child Neurol, 2001

  34. Methods 3 years Chronic daily or nearly daily headache & excessive analgesic intake Headache characteristics: type, location, duration, intensity History of migraine

  35. Methods Physical & neurological evaluation Abrupt withdrawal of medication Headache diary Follow-up: 2, 4, 8, 12, 24 weeks

  36. Results 19 girls & 7 boys Age: 14.2 (12-18) y Mean headache duration: 1.6 (0.3-4.5) y Headache: Constant, dull, generalized, 4-6 Mean headache days/month: 28.1 (19-31) No history of migraine prior to CDH

  37. Results Analgesic consumption At least 1 drug for each headache 16 youngsters: daily Weekly intake: 28.1 (19-41) tablets

  38. Results Analgesic type 21 - Paracetamol 5 - Combination; 4 Rokacet 1 Rokal Family headache history: 34.6%

  39. Withdrawal resultsMean headache frequency 1st month: 24.9 to 8.2 2nd month: 2.6 (p<.001) 3rd month: 20 - Complete cessation 5 - episodic migraine 1 - No change

  40. Conclusions Analgesic induced headache occur in adolescents Simple analgesics Abrupt withdrawal Successful, no hospitalization Mechanism: Serotonin

  41. Caffeine induced headache Most widely: tea, coffee Worldwide daily caffeine: 70 mg Caffeine abuse Caffeine excessive/withdrawal: headache CDH in children & adolescents and excessive caffeine: cola drinks

  42. Caffeine in cola drinks(mg per can) Coca-Cola, Diet Coca-Cola 45.6 Pepsi Cola, Diet Pepsi Cola 37.2 RC Cola, Diet RC Cola 36 Shasta Cola 44.4 Canada Dry Cola 30

  43. Methods 5 years 19 boys, 17 girls (56/49) CDH & Excessive caffeine Headache characteristics: type, location, duration, intensity History of migraine

  44. Methods Physical & neurological evaluation Gradual withdrawal of cola Headache diary Follow-up: 2, 4, 8, 12, 24 weeks

  45. Results Age: 9.2 y (6-18) Mean headache duration: 1.8 (0.6-5) Cola consumption: At least 1.5 liters/day Mean weekly: 11 liters (10.5-21) Caffeine consumption: At least 192.88mg Mean weekly: 1414.5mg (1350.1-2700.3)

  46. Results Headache characteristics: Constant, dull, generalized, 4-7 Family headache history: 19.4%

  47. Withdrawal results Cola discontiuation:1-2 weeks Complete headache cessation: 33/36 3 Adolescents (1 M, 2 F): migraine

  48. Conclusions Children & adolescents with high daily caffeine consumption may suffer from caffeine induced headache Successful gradual withdrawal

  49. Thank you for your attention

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