Exploring Nelson with Vasu : CNS 1

7:54:00 PM
From today DNBPEDIATRICS.COM is publishing a series of blog-post, for asynchronous learning written by Dr Vasu Burli which are actually his handpicked notes he derived from Nelson Textbook of Pediatrics during his post graduate residency in pediatric. The notes are divided system-wise. The first in this series is ready to go online! so sit tight and note down.

Series 1: CNS Questions

1. Headache
        About Dr Vasu Burli
Budding intensivist, currently persuing Pediatric critical care fellowship from Apollo Chennai, did his DNB in Pediatrics from renowned institute Kanchi Kama -Koti CHILD’S trust Hospital, Chennai. His area of interest are pediatric Intensive care and Emergency medicine.

Headache is a common complaint in children and teenagers.
Types:
Primary: Migrane and tension type headache.
Secondary: Due to an underlying illness.
Migrane: Migraine is the most frequent type of recurrent headache that is brought to the attention of parents and primary care providers.

Classification:

1. migrane without aura
2. migrane with aura
3. childhood periodic syndromes that are commonly precursors of migrane
4. retinal migrane
5. complications of migrane
6. probable migrane

Criteria:

All these features can be with or without aura
I
II
Headaches lasting 4-72 hr (untreated or unsuccessfully treated)
III
Headaches with at least two characteristics (UPMA)
A
U   unilateral location
B
P    pulsating quality
C
M   moderate of severe pain intensity
D
A  aggravation by or causing avoidance of routine physical activity
IV
During the headache have at least 1 of the following:
A
B
Photophobia and phonophobia
V
Not attributed to another disorder

In addition to the classifying features, there may additional markers of a migraine disorder. These include such things as triggers (skipping meals, inadequate or irregular sleep, dehydration and weather changes are the most common), pattern recognition (associated with menstrual periods in adolescents or Monday morning headaches due to change in sleep patterns over the weekend), and prodromes (a feeling of irritability, tiredness, and food cravings prior to the start of the headache).

INDICATIONS FOR NEUROIMAGING IN A CHILD WITH HEADACHES

1. Abnormal or focal neurologic signs or symptom
2. Seizures or very brief auras less than 5 min
3. Unusual headaches in children 
4. Headache in any children below 6 years or any child that can not describe their headache
5. Brief cough headache in a child or adolescent
6. Headache worst on first awakening or that awakens the child from sleep
7. Migrainous headache in the child with no family history of migraine or its equivalent

Treatment:

Acute treatment:  
This mainly includes 2 groups of medicines: nonsteroidal antiinflammatory drugs (NSAIDs) and triptans. Ibuprofen has been the most well documented at a dose of 7.5-10 mg/kg. The most effective way to administer the NSAIDs and triptans is to use the NSAIDs first, restricting their use to fewer than 2-3 times per wk, and adding the triptan for moderate to severe attacks. Fluid hydration should be integrated into the acute treatment plan.

Preventive therapy:
The most commonly used preventive therapy for headache and migraine is amitriptyline usually given for at least 4-6 months at an adequate dose and then weaned over several weeks time. Antiepileptic medications are more recently commonly used for migraine prophylaxis.
Biobehavioral  therapy:    Biobehavioral evaluation and therapy is essential for effective migraine management. This should include adequate fluid intake without caffeine, regular exercise, not skipping meals and making healthy food choices, and adequate (8-9 hr) sleep on a regular basis. Biofeedback-assisted relaxation therapy has been demonstrated to be effective for both acute and preventive therapy.

Secondary headache:
By definition, a secondary headache has a specific cause and should resolve once this cause is treated. If the headache persists, the diagnosis and treatment should be questioned because either the diagnosis may be incorrect, the headache may be a primary headache, and/or the treatment chosen may have been incorrect.

Causes of secondary headache
      Headache attributed to head and/or neck trauma
      Acute post-traumatic headache
      Medication-overuse headaches
      Headache attributed to Rhinosinusitis
      Headache attributed to psychiatric disorder
      Headache attributed to nonvascular intracranial disorder
   
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