Pediatric Primary Care Case Studies (82 page)

•   How did the headache begin? Asking about head trauma or recent changes in the child’s social situation is an important part of this question.

•   What is the time of onset of headache during the day? Ask about night waking due to headache, relationship to activity, or coughing causing the headache. Headache associated with coughing is an ominous sign (Gunner & Smith, 2007). Headaches that are predominantly nocturnal or early morning and associated with vomiting deserve neuroimaging (Brna & Dooley, 2006).

•   How long does the headache episode last? Cluster headaches tend to be brief; migraines can last as short as 1 hour and as long as 72 hours; and TTHs can last the entire day (Brna & Dooley, 2006).

•   Where is the headache located on the head? Bitemporal frontal headache is common in migraine whereas tension headache is around the head. Occipital headaches are an ominous sign and may indicate structural lesions (Gunner & Smith, 2007).

•   What makes the headache better or worse?

•   What are the characteristics of the pain? Younger children may describe migraine as pressing or heavy rather than throbbing (Brna & Dooley, 2006). The inability to locate the pain is more disturbing than not being able to describe it (Brna & Dooley).

•   Are there any warning signs that the headache is coming? Auras that are persistently unilateral on the same side should have neuroimaging to rule out structural lesions (Brna & Dooley, 2006). Parents may be able to note changes in the child’s appetite, mood, or thirst.

•   What are the associated symptoms? Are there associated autonomic symptoms such as nausea, vomiting, numbness, or weakness? If the child complains of dizziness, you will need to ask more questions. Is the patient describing lightheadedness, unsteadiness, or vertigo? Lightheadedness suggests cerebral hypoperfusion or orthostasis (Lewis, 2007b). Unsteadiness or vertigo is associated with balance disorders, suggesting the need for neuroimaging to rule out vestibular or cerebellar pathology (Lewis, 2007b). Dizziness and vertigo at the onset of a throbbing headache suggest basilar-type migraine, which is a more complex type of migraine requiring referral (Lewis, 2007b).

•   Do the headaches occur under any specific circumstances or after eating any particular food? Migraines may have a trigger.

•   What makes the headache better or worse? Aggravating factors can include activities, light, noise, and smell. Headaches caused by increases in intracranial pressure will get worse when the child lies down (Brna & Dooley, 2006).

•   What does the child do during the headache? Ask the child what he does if he gets the headache during playtime.

•   What medications are taken for the headache? What other medications is the child taking? Asking specifically about alternative medications is also important. Headaches can be the side effects of other medications.

•   Does the child have any other medical/psychiatric problems? Make sure there is no chronic health condition that may be causing headache or stress

•   Would I as a healthcare provider know your child has a headache if I saw him?

•   Has the child had a change in personality with the onset of the headache?

•   Does anyone in the family have headaches? The genetics of migraine need to be explored.

•   What does the parent think is causing the headaches?

•   Is there any drug or alcohol use?

•   What is the child’s sleep pattern? Does the child snore? Is there daytime sleepiness? Children with migraine have increased sleep disturbances (Heng & Wirrell, 2006; Isik et al., 2007).

•   Are there any behavioral problems with the child? Children with headaches were initially thought to have psychopathology. However, recent reviews and studies have failed to show that a majority of children with headache have any psychopathology (Laurell, Larsson, & Eeg-Olofsson, 2005; Powers, Gilman, & Hershey, 2006; Vannetta et al., 2008)

•   If the child is a female adolescent, does she use oral contraceptives?

•   Does the child have a history of 2 weeks or more of purulent nasal discharge?

•   When was the child’s last visit to the dentist?

In addition to the data described earlier, you now learn on further questioning that with the first headache, there was no nausea reported but now Mr. Brown reports that John does not look well during the headache episodes. He does not feel the child has any aura. The headache is improved by lying down, but Tylenol provides only minimal relief. After sleeping, John is generally better. He has had about two to three headaches a month.

After the first headache, Mr. Brown took John to the doctor, and the child was diagnosed with a tension headache. The father was advised to use Tylenol. After 6 weeks and three more headaches, John was seen by a second provider who did a CT scan, CBC, lead level, and thyroid screen. The results were all normal by the father’s report and the family was given no further follow-up visits. Mr. Brown has not been able to identify a precipitating cause but has not done a headache diary. John has had no associated head trauma or change in social situation. There are no other medical problems, and the father has not noted John to have purulent rhinitis. John’s behavior and school performance is the same. He sees a dentist regularly. He generally sleeps 10 hours a night, but does report variability in sleep time. John eats three meals per day, and there has been no change in bowel or bladder habits. The maternal grandmother has babysat for the child for the past 3 years since the death of the mother. The previous medical record was not available at the time of the initial visit, but was later obtained and confirmed the father’s history.

Physical Examination

John is at the 75th percentile in height and the 50th percentile in both head circumference and weight. His body mass index (BMI) is between the 50th and 75th percentile and his BP is normal. Developmentally, the child is able to answer questions and draw a diamond. He is able to read on grade level and do simple math and reading.

From the general physical examination, the following observations were made: There is one 1.5 cm café au lait spot on the right trunk but no other neurocutaneous manifestations.
There is no tenderness over the maxillary sinus, and the nasal mucosa is pink with exudate. The mouth opens without clicking or popping of the temporomandibular joint. No caries are seen and there is no evidence of gingivitis. The cervical spine has full range of motion. Heart, lung, and abdomen examinations are normal.

A complete neurological exam was done. No cranial bruit was identified. Visual fields: grossly intact by confrontation. Visual acuity is 20/20, and extraocular movements are intact without nystagmus. The optic disc is sharp with normal disc to cup ratio. There is no blurring of the vessels along the disc margins. Pupils are equal, round, and reactive to light and accommodation. Fifth (trigeminal) nerve: intact bilateral masseter strength. Seventh (facial) nerve: face bilaterally symmetric; eighth (auditory) nerve: intact bilateral hearing; ninth (glossopharyngeal) nerve: normal gag; 11th (spinal accessory) nerve: full strength in bilateral trapezius and SCM; 12th (hypoglossal) nerve: tongue midline. Reflexes +2 symmetrical on all four extremities without clonus and with downgoing toes. Motor: right upper extremity muscle: normal; left upper extremity muscle: normal; right lower extremity muscle: normal; left lower extremity muscle: normal. Other: Able to walk on heels and hop three times on each foot. Right hand, right foot preference, able to do tandem gait. Sensory primary: Light touch: intact; Pinprick: intact. Secondary: Graphesthesia: able to perform; Stereognosis: able to perform. No neurological soft signs such as hyperactivity, poor attention span, or impulsivity demonstrated during exam. Coordination: dysdiadochokinesis (i.e., inability to quickly substitute antagonistic motor impulses) attempted. Gait: normal for age without ataxia.

In summary, no abnormal findings were identified in the physical examination.

Making the Diagnosis

The history and physical examination are consistent with the diagnosis of migraine headache. The need for neuroimaging should be considered when there are either historical features of recent onset of severe headache, changes in type of headache, or changes in neurological function (Lewis, 2007b). The need for neuroimaging should be considered if there are physical examination features of focal findings, increased intracranial pressure, or new onset of seizures. (See
Table 20-2
.) The child’s history and physical have no worrisome characteristics and meet the criteria for pediatric migraine rather than tension-type headaches.

Management

How do you plan to treat his migraine headaches?

Do you need to do anything to confirm the diagnosis, such as laboratory studies?

No laboratory studies are recommended in the management of pediatric migraine (Guidetti & Galli, 2004; Gunner & Smith, 2007; Lewis, 2007a, b, c). Neuroimaging or lumbar puncture should be done if there are abnormalities during the history or physical examination that indicate the need for further testing.

Therapeutic plan: What will you do therapeutically?