Headache

Question 1

Red flags for headache

Answer 1

• Acute and severe
• Progressive chronic headaches
• Focal neurology
• Age under 3yrs
• Headache/vomiting on waking
• Consistent location of recurrent headaches
• Presence of VP shunt
• Hypertension

Question 2

What are the commonest types of recurrent headaches?

Answer 2

• Tension-type Headaches (~50% incidence):
  
  • Non-pulsatile band
  • Often end of day
  • Few associated symptoms
• Migraines (~25%):
  
  • Pulsing pain
  • Nausea
  • Photophobia
  • Phonophonia
  • Often unilateral

Question 3

6 causes of headache other than tension/migraine

Answer 3

• 1) Fever without associated meningism
  
  • URTI
  • Pneumonia
  • Septicaemia
• 2) Local sinusitis
  
  • Focal facial tenderness
  • Otitis media
• 3) History of recent head injury
  
  • Consider concussion
• 4) Meningitis
  
  • Irritability
  • Decreased consciousness
  • Petechiae/purpura
  • Photophobia/neckstiffness
  • Nb: classic signs less common in paediatric population
• 5) SAH
  
  • Sudden onset (“thunderclap”)
  • Vomiting
  • Often occipital
• 6) Rebound/overuse headache

Question 4

What tools are used for assessing headache?

Answer 4

1. Headache Patterns
2. HEADSS (Home/Education/Activities/Drugs/Sexuality/ Suicide&depression)
3. International Headache Society: Guidelines

Question 5

What sort of finding warrant investigation?

Answer 5

• Abnormal neurology
• Meningism (consider LP)
• Marked changes in behaviour
• Symptoms of raised intracranial pressure
• Increasing frequency of undiagnosed headaches
• Onset of severe headach

Question 6

Describe the different patterns of headache

Answer 6

a) Acute recurrent

• Migraine (common, classical, complicated)

b) Chronic non-progressive

• Tension
• Anxiety
• Depression
• Somatisation

c) Chronic progressive

• Tumour
• Benign intracranial hypertension
• Brain abcess
• Hydrocephalus

d) Acute on Chronic non-progressive

• Tension headache with coexistant migraine

Question 7

Management of headache vs migraine?

Answer 7

Question 8

Safety netting advice for child with headache

Answer 8

See your doctor if:

• the headaches are getting worse
• they are waking your child up from sleep
• they are worse in the morning
• your child has persistent vomiting
• you notice changes in your child’s behaviour or personality

Question 9

What are the commonest organisms causing bacterial meningitis in children over 2 months of age

Answer 9

• Streptococcus pneumoniae
• Neisseria meningitidis
• Haemophilus influenzae type B (in unimmunised children)

Question 10

What are some organisms to consider in meningitis in infants less than 2 months of age?

Answer 10

• Group B streptococcus
• E. coli and other Gram-negative organisms
• Listeria monocytogenes
• Streptococcus pneumoniae
• Neisseria meningitidis
• Haemophilus influenzae type B (in unimmunised children)

Question 11

Causes of encephalitis?

Answer 11

• Enterovirus
• HSV
• Other herpes viruses (EBV, CMV, HHV6, VZV)
• Arboviruses.
• Less commonly, encephalitis can be caused by bacteria, fungi or parasites.

Question 12

Common clinical picture of a child with meningitis?

Answer 12

• Infants with meningitis frequently present with non-specific symptoms such as fever, irritability, lethargy, poor feeding, vomiting and diarrhoea
• Older children may complain of headache or photophobia
• Seizures
• Prior antibiotics - clinical presentation may be altered by prior use of antibiotics.

EXAMINATION

• In infants, the fontanelle may be full
• Neck stiffness may or may not be present (not a reliable sign in young children)
• A purpuric rash is suggestive of meningococcal septicaemia
• Kernig’s sign: hip flexion with an extended knee causes pain in the back and legs
• CSF shunts, spinal and cranial abnormalities (eg dermal sinuses) which may have predisposed a child to meningitis
• Signs of encephalitis: altered conscious state, focal neurological signs

Question 13

Investigations for meningitis?

Answer 13

• Lumbar puncture (LP)Prior to performing a LP
  
  • discuss with a senior registrar or consultant.
  • Sterilisation of the CSF can occur within 2 hours after a dose of Ceftriaxone 50 mg/kg/dose (2g) iv 12H /Ceftriaxone for N. meningitidis and within 4 hours for S. pneumoniae
• Blood tests
  
  • Full blood count/differential
  • Glucose, urea and electrolytes
  • Blood cultures

Question 14

What is the initial management of meningitis?

Answer 14

<2 months

• Cefotaxime 50 mg/kg (max 2g) iv 6H AND
• Benzylpenicillin* 60 mg/kg iv
• 12H (wk 1 of life)
• 6-8H (wk 2-4 of life)
• 4H (>4 weeks of life)

> 2 months

• Ceftriaxone 50 mg/kg/dose (2g) iv 12H
• Dexamethasone 0.15mg/kg IV 6 hourly for 4 days

If encephalitis is suspected on examination then give:

• Aciclovir