Headache

Agenda

• History

• Physical

• Classification

• Management

History

• Chronicity– Duration– Frequency– Acute vs. chronic

• Location• Severity• Radiation• Quality/character

• PMH• Family History• Medications• Ameliorating or

exacerbating factors• Social History and

effect on activity

Physical

• ABCs• Vitals • HEENT – fundoscopic exam• CV• Pulm• MSK – reproducible (TMJ, occipital, etc.)• Neuro• Skin

Classification

Primary• Tension – bilateral

tightness, intermittent and recurring

• Cluster – unilateral, frontal-periorbital

• Migraine – paroxysmal w/ autonomic symptoms, chronic and remitting

• Chronic daily headache• Idiopathic intracranial

hypertension

Secondary• Infection

– Meningitis– Encephalitis– Abscess– Central venous thrombosis– Sinusitis– Pharyngitis– Otitis media

• Tumor• Intracranial hemorrhage• CO poisoning• Hypertension

Management

• Neuro imaging not indicated for recurrent HA w/ normal neuro exam

• Consider CT for new onset migraine w/ normal exam

• MRI for HA associated w/ sleep, emesis, and/or abnormal exam inc. skin findings

• LP after imaging if concerned for infection or increased ICP

Management

All headaches• NSAIDs

– Ibuprofen– Naproxen– Ketorolac

• Acetaminophen• Amitriptyline• Biofeedback• Counseling

Migraines• Abortive

– Antimemetics– Ergotamine– Triptans

• Prophylactic– Cyproheptadine– B blockers– Valproate + folate– Amitriptyline– Other AEDs

References• Lewis DW, Dorbad D. The utility of neuroimaging in the

evaluation of children with migraine or chronic daily headache who have normal neurological examinations. Headache. 2000 Sep;40(8):629-32.

• Brazis, Paul, et al. Approach to the child with headache. www.uptodate.com

• Cruse, Robert. Classification of migraine in children. www.uptodate.com

• Cruse, Robert. Management of migraine headache in children. www.uptodate.com

• Cruse, Robert. Tension headache in children. www.uptodate.com• King, Christopher. Emergent evaluation of headache in children.

www.uptodate.com