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Understanding Pediatrics: Headaches in Pediatrics

Tension headaches

  • Worsens during the day
  • Triggered by stress
  • Band like aching over forehead
  • Posterior neck muscle tenderness
  • Episodic

Migraine headaches

  • Most common cause of recurrent headache
  • POUND mnemonic
    • Pulsatile
    • Onset 4-72 hours
    • Unilateral
    • Nausea/vomiting
    • Debilitating
  • More severe than tension headache
  • Phonophobia
  • Photophobia
  • Triggers
    • Smells
    • Sounds
    • Stress
  • Classic vs common
    • Classic – with aura (lights, sounds, tingling)
    • Common – without aura, seen more often in children
See the source image

Basilar migraine

  • Uncommon form of migraine where the symptoms of the migraine resemble ischemia of the territory of the brain supplied by the basilar artery
    • Ataxia
    • Loss of vision
    • Dysarthria
    • Paraesthesia
    • Vomiting

Idiopathic intracranial hypertension (pseudotumor cerebri)

  • Mismatch between production and resorption of CSF leading to increased intracranial fluid, or due to abnormalities in cerebral blood flow
  • Causes
    • Idiopathic
    • Obesity
    • Excess vitamin A
    • Tetracyclines
    • Infections
  • Diagnosis
    • Usually normal MRI
    • Confirmed with lumbar puncture
      • Elevated opening pressure
      • Normal CSF analysis
    • 3 diagnostic criteria
      • Increased intracranial pressure as evidenced by elevated opening pressure on LP and/or symptoms
      • Normal brain anatomy
      • Normal CSF analysis
    • Neurological exam and fundoscopy may reveal peripheral loss of vision which is one of the complications IIH if left untreated
  • Treatment
    • First line – acetazolamide – decreases production of CSF
    • Second line – add furosemide
    • Surgery
      • CSF shunt
        • Lumboperitoneal shunt – directs CSF from the subarachnoid space of the lumbar space to the peritoneum
        • Ventriculoperitoneal shunt – directs CSF from one of the ventricles in the brain to the peritoneum
        • Cisterna magnum – last resort shunt, directs CSF from the cervical cistern to the peritoneum
      • Cerebrospinal stenting
        • If imaging have revealed major narrowing of a major vein or sinus, which is causing the intracranial pressure to also rise, a stent can be placed to open the vein or sinus back up

Directed history of headaches in pediatrics

  • Sudden onset – can be a sign of SAH or intracranial hemorrhage
  • Most severe headache, or unlike previous headaches
  • Increased intracranial pressure
    • Projectile vomiting – increased intracranial pressure
    • Headaches that occur after a long period of lying down (morning, or nap) – increased intracranial pressure
    • Awakens from sleep – increased intracranial pressure
    • Worsens with cough or Valsalva – increased intracranial pressure
    • Cushing’s triad of increased intracranial pressure
      • Bradycardia
      • Irregular respirations
      • High blood pressure
  • Fever and photophobia – while photophobia is seen in pediatrics, both fever and photophobia are also seen in meningitis or encephalitis which can be life threatening
  • Progressively worsening – increasing in frequency and severity over time
  • Longstanding headache that is acutely worse – points to underlying pathology, needs investigation
  • Associated neurological symptoms
  • History of allergies – points toward sinusitis
  • Poor visual acuity, difficulty reading or seeing the board – poor eyesight can lead to recurrent headaches