Pediatric Headaches – Turner

Majority of children are diagnosed with viral illness or migraine in the ED/UC setting.

DDx:

Infection:  viral meningitis, bacterial meningitis, orbital or cerebral abscess.

Tumor:  isolated headache is a rare manifestation of a brain tumor.

Intracranial hemorrhage:  non-traumatic (not typically HA alone)

Carbon monoxide poisoning

Hypertension:  essential, pheo

Common secondary causes:

  • fever
  • viral meningitis
  • pharyngitis (including strep)
  • influenza
  • OM, sinusitis, dental infection

Migraine:

  • menstrual migraine (catamenial)
  • hemiplegic (unilat weakness w migraine, it’s the “motor aura” with the migraine) – this is a familial condition related to known genes
  • migraine with brainstem aura (formerly “basilar-type” migraine) – vertigo, dysarthria, tinnitus, diplopia, paresthesias, decreased LOC.
  • retinal migraine (rare) – vision can be permanently lost, retinal exam abnormal during attack
  • cyclic vomiting syndrome
  • abdominal migraine (HA not prominent) – N/V, pallor, protracted vomiting NOT common (think CVS)

Evaluation:

  • Worrisome history:  wakes from sleep, fever, neck pain, vomiting, behavior changes, vision changes.
  • Physical exam:  Palpate everything – head, TMJ, sinuses, etc.  Skin – look for rashes, cafe au lait spots, ash leaf spots.  Neuro – always do a fundoscopic exam!
  • Neuroimage if:  first HA of its type, chronic progressive HA, age < 3 with unexplained severe HA, skin lesions suggestive of neurocutaneous syndrome, abnormal neuro exam.
  • LP:  see handout for indications and studies.

See Children’s Hospital slides for RED FLAGS and other useful information.

For migraine prophylaxis in kids:  cyproheptadine (but take care in obese kids – it’s an appetite stimulant) is first line!

 

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