Headache (peds): Difference between revisions
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | |- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Migraine | | valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Migraine | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | [[Ibuprofen]], 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Ibuprofen superior to acetaminophen in one trial<br/> | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Ibuprofen superior to [[acetaminophen]] in one trial<br/> | ||
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | |- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sumatriptan, 10 milligrams via nasal spray (20–39 kg) or 20 milligrams via nasal spray (>40 kg), or 0.06 milligram/kg SC | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | [[Sumatriptan]], 10 milligrams via nasal spray (20–39 kg) or 20 milligrams via nasal spray (>40 kg), or 0.06 milligram/kg SC | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Nasal or injectable preferred; no difference between oral sumatriptan and placebo<br/> | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Nasal or injectable preferred; no difference between oral sumatriptan and placebo<br/> | ||
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | |- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ||
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| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | — | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | — | ||
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | |- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Sumatriptan | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | [[Sumatriptan]] | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Nasal spray or IM dosing as for migraine | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Nasal spray or IM dosing as for migraine | ||
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | |- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Lidocaine, 1% solution in ipsilateral nostril | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | [[Lidocaine]], 1% solution in ipsilateral nostril | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Effective for mild to moderate pain, can instill via atomizer and syringe | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Effective for mild to moderate pain, can instill via atomizer and syringe | ||
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | |- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Prednisone, 1–2 milligrams/kg for 10 d with subsequent 7-d taper | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | [[Prednisone]], 1–2 milligrams/kg for 10 d with subsequent 7-d taper | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Effective at terminating prolonged cluster headaches and preventing recurrence | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Effective at terminating prolonged cluster headaches and preventing recurrence | ||
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | |- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Tension | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Tension | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | [[Ibuprofen]], 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | ||
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | — | | valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px;" | — | ||
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Revision as of 00:39, 15 September 2019
See also Headache
Background
Headache Red Flags
Features
- Sudden onset or accelerating pattern
- Maximum intensity of pain at onset (i.e. "thunderclap")
- Worse with valsalva
- Worse in the morning or at night
- No similar headache in past
- Age >50 yr or <5 yr
- Occipitonuchal headache
- Visual disturbances
- Exertional or postcoital
- Family or personal history of SAH, cerebral aneurysm, or AVM
- Focal neurologic signs
- Diastolic BP >120
- Papilledema
- Jaw claudication
Clinical Context
Headache in setting of:
- Infection
- Cancer
- Immunosuppression
- Seizure
- Syncope
- Trauma
- Altered mental status
- Systemic illness (fever, stiff neck, rash)
- Nausea/vomiting
- Patient on anticoagulation, steroids, NSAIDs, antiplatelet
Clinical Features
Differential Diagnosis
Pediatric Headache
- Primary headache
- Secondary headache
Evaluation
Exam
- General appearance and behavior
- CNs
- Nuchal rigidity
- Papilledema
- Ataxia
- Other signs of infection (e.g. rhinorrhea, pharyngitis, flank pain, etc.)
Work-up
- Neuroimaging if red-flag features
- Routine imaging is not indicated in children with recurrent HA headaches and normal neuro exam
- Consider imaging if abnormal neuro exam, altered mental status, concurrent seizure, severe HA or change in type
Diagnosis
- Predictors of a surgical space-occupying lesion
- Headache of <6 months duration
- Sleep-related headache
- Vomiting
- Effortless vomiting but no GI complaints suggestive of elevated ICP
- Confusion
- Absence of family history of migraine
- Abnormal findings on neuro exam
- Torticollis
- Strongly consider imaging in patients under 5 yrs who present with headaches
Management
Headache Type | Treatment | Comment |
---|---|---|
Migraine | Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | Ibuprofen superior to acetaminophen in one trial |
Sumatriptan, 10 milligrams via nasal spray (20–39 kg) or 20 milligrams via nasal spray (>40 kg), or 0.06 milligram/kg SC | Nasal or injectable preferred; no difference between oral sumatriptan and placebo | |
Rizatriptan, 5 milligrams PO | Efficacy not statistically significant over placebo | |
Dihydroergotamine, 0.1 milligram/kg (ages 6–9), 0.15 milligram/kg (ages 9–12), 0.2 milligram/kg (ages 12–16) | Contraindicated in complex migraine | |
Prochlorperazine, 0.15 milligram/kg IV | Consider diphenhydramine 1 milligram/kg to prevent or treat dystonic reactions | |
Cluster | 100% oxygen at 7 L/min via non-rebreather mask at onset of headache | Most useful at onset of symptoms, less effective later in course of headache |
Ergotamine, 0.1 milligram/dose (ages 6–9), 0.5 milligram/dose (ages 9–12), 0.75 milligram/dose (ages 12–16) | — | |
Sumatriptan | Nasal spray or IM dosing as for migraine | |
Lidocaine, 1% solution in ipsilateral nostril | Effective for mild to moderate pain, can instill via atomizer and syringe | |
Prednisone, 1–2 milligrams/kg for 10 d with subsequent 7-d taper | Effective at terminating prolonged cluster headaches and preventing recurrence | |
Tension | Ibuprofen, 10 milligrams/kg PO, or acetaminophen, 15 milligrams/kg PO/PR | — |
Disposition
- Discharge if primary headache provided pain is well controlled and child is well-appearing