Pediatric Head Injuries/Migraines

From Pediatric Emergency Medicine, sponsored by Nemours

Educational Objectives

The goal of this program is to improve the management of pediatric head trauma and migraine headaches. After hear­ing and assimilating this program, the clinician will be better able to:

1.   Recognize the factors that warrant use of computed tomography  in patients with head trauma suspected of having traumatic brain injury (TBI).

2.   Utilize the modified American Academy of Pediatrics practice parameters for pediatric patients with TBI.

3.   Employ the modified Centers for Disease Control and Prevention guidelines for managing the athlete with concussion.

4.   Describe the criteria for diagnosis of migraine with or without aura in children.

5.   Determine when neuroimaging is appropriate in the pediatric patient with migraine.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Drs. Patel and Knapp and the planning committee reported nothing to disclose. Dr. Knapp presents information in her lecture that is related to off-label or investigational use of a therapy, product, or device.

Acknowledgements

Drs. Patel and Knapp were recorded at Pediatric Emergency Medicine, held April 15-18, 2009, in Lake Buena Vista, FL, and sponsored by Nemours. The Audio-Digest Foundation thanks Dr. Patel, Dr. Knapp, and Nemours for their cooperation in the production of this program.

Minor Head Trauma: Controversies in Management

Parul B. Patel, MD, MPH, Assistant Professor of Pediatrics, Thomas Jefferson Medical College, and Attending Physician, Pediatric Emergency Department, A. I. duPont Hospital for Children, Wilmington, DE

Definitions: minor head trauma (mHT) or minor blunt head trauma (mBHT) usually defined as Glasgow Coma Scale (GCS) score of 14 to 15, with or without brief loss of consciousness (LOC); intracranial injury (ICI) or traumatic brain injury (TBI) includes intracranial hemorrhage (ICH), hematoma, cerebral edema, or diffuse axonal injury

Primary focus: identify TBI in patients with mHT that can lead to morbidity and mortality if untreated; identify sur­gically correctable primary injury; prevent secondary injury, eg, brain hypoxia or ischemia, hypercarbia, and in­creased intracranial pressure (ICP); primary survey  —  includes airway, breathing, and circulation; cervical (C)-spine and disability; secondary survey  —  head-to-toe examination, with complete neurologic examination and fun­duscopy whenever possible

Computed tomography (CT): pros  —  shows TBI and prevents mortality; if suspicion high for TBI, benefits out­weigh risks; relieves parents of worry; early disposition; cons  —  radiation exposure from CT of head equivalent to 300 to 500 chest x-rays; children have higher lifetime risk for radiation-related cancer  risk (1 in 2000 for infants, 1 in 5000 for older children); sedation and associated risks; need to transport child out of emergency department (ED); cost

Clinical predictors of TBI that warrant CT: data clear for patients with decreased mental status (MS), neurologic deficits, and signs of basilar skull fracture

By history: seizure; altered MS, including decreased level of consciousness; persistent vomiting; progressive head­ache; coagulopathy; amnesia; TBI may occur in absence of symptoms (uncommon); LOC  —  stated that should obtain CT of head in any child with LOC, but found that only 3% to 6% had TBI and of those, small percentage needed surgical intervention; in studies, duration of LOC varies; in study by Palchak, none of 125 participants with isolated brief LOC had ICI

By physical examination: focal neurologic deficits; altered MS; signs of skull fracture  —  association with TBI var­ied in studies; depressed and basilar skull fracture highly associated; scalp hematoma  —  risk depends on location and size, and correlates with skull fracture and age of child; in general, the larger the hematoma, the higher the risk; temporal and parietal hematomas highest risk, followed by occipital hematoma; frontal hematoma low risk; higher risk with skull fracture; the younger the child, the thinner the bone, the higher the risk

American Academy of Pediatrics (AAP) practice parameters for patients 2 to 20 yr of age: for previously neuro­logically healthy children with isolated head injury (LOC <1 min, vomiting, seizure, and headache immediately af­ter injury), normal MS, no focal deficits, and no signs of skull fracture; for patients with minor head injury and no LOC (no other symptoms and normal neurologic examination), observation in ED or clinic, then £24 hr at home with reliable observer and clear instructions; for children with minor head trauma with LOC <1 min and no other concerning history with normal examination, CT or observation as previously described; for those with minor head trauma with abnormal neurologic examination or sign of skull fracture, CT of head

Risk categorization for children <2 yr of age: treated differently due to higher risk for skull fracture and occult TBI even after minor mechanism; clinical assessment difficult; 19% to 48% of infants with TBI asymptomatic; infants <3 mo of age especially difficult; risk factors for TBI  —   caveats for infants <3 mo of age (limited behavioral reper­toire and high incidence of TBI after relatively minor mechanisms); high risk —  CT required; depressed MS; focal neurologic signs; signs of depressed or basilar fracture; seizure; irritability; acute skull fracture; bulging fontanelle; progressive vomiting; LOC >1 min; underlying or predisposing condition; intermediate risk  —  CT or observation for 4 to 6 hr recommended; 3 to 4 episodes of vomiting; LOC <1 min; history of lethargy or irritability now re­solved; parental concern about child’s behavior; nonacute skull fracture (>24 hr); CT and/or x-ray or observation for 4 to 6 hr recommended in children who fall with great force onto hard surface, unwitnessed event, vague or no history but with symptoms of head trauma, and scalp hematoma (especially large and nonfrontal); low risk  —  no imaging, with observation for 4 to 6 hr recommended; low-energy mechanism; no signs or symptoms; >2 hr since injury; older age more reassuring; lower threshold for imaging of infants <2 to 3 mo of age with trauma, unless triv­ial, even without symptomatology; consider clinical scenario and need for sedation

Skull x-rays: give no direct information about TBI and have poor negative predictive value and specificity; predict TBI in infants and young children, ie, 15% to 30% of children with skull fracture had TBI; use as screening tool if CT not readily available or as part of examination if suspicion of TBI low

Disposition: observation  —  4 to 6 hr in ED or clinic or office and ³24 hr with reliable observer and clear instructions; with negative head CT  —  chances of late deterioration zero in 261 patients in 3 studies; Pediatric Emergency Care Applied Research Network (PECARN) study found 100% negative predictive value for neurosurgical intervention for normal CT in patient with initial GCS score of 15; children with linear skull fracture and negative head CT sent home

Concussion: clinical syndrome  —  immediate and transient alteration in brain function; includes altered MS and level of consciousness; from mechanical force or trauma; confusion and amnesia hallmark symptoms, early (minutes to hours) or late (days to weeks); with or without LOC; relevance  —  in postconcussive syndrome, symptoms last weeks to months; second-impact syndrome acute, often fatal, brain swelling with second concussion without com­plete recovery from first; due to loss of autoregulation of brain blood supply

Modified Centers for Disease Control and Prevention (CDC) guidelines for concussion: grade 1  —  transient con­fusion, no LOC, and MS abnormality <15 min; return to sports same day if symptoms <15 min; for second grade 1 concussion, no sports until asymptomatic for 1 wk; grade 2  —  transient confusion, no LOC, and MS abnormality >15 min; no sports until asymptomatic for 1 wk; if on same day as grade 1, no sports until asymptomatic for 2 wk; grade 3  —  LOC; if LOC brief, no sports until asymptomatic for 1 wk; if LOC prolonged, no sports until asymptom­atic for 2 wk; for second grade 3 concussion, no sports activity until asymptomatic for 1 mo; if pathology detected on CT or magnetic resonance imaging (MRI), no sports for remainder of season; athlete discouraged from return­ing to sports

Return to play: all guidelines agree that athlete should not play while symptoms present; must be asymptomatic at rest and exertion; clearance by primary care physician (PCP) necessary before returning to sport; CDC toolkit ex­cellent resource

The Child with a Migraine Headache

Jane F. Knapp, MD, Professor and Associate Chair, Department of Pediatrics, University of Missouri, Kansas City, School of Medicine; Director of Graduate Medical Education, Children’s Mercy Hospital and Clinics, Kansas City, MO

Prevalence of migraine: can start in childhood, even in infancy; underrecognized and underdiagnosed in children; often misdiagnosed as secondary headache syndrome;  prevalence increases as children become older; male-to-fe­male ratio switches; in younger children (3 to 7 yr of age), male preponderance; sexes equivalent during school-age years; female preponderance in teenage years; by adolescence, 25% report migraine headaches; in children  —  auras less common; bilateral tendency; attacks relatively brief (1-4 hr) and easier to treat; unusual presentations more common, usually involving neurologic symptoms, eg, altered MS; autonomic symptoms, eg, phonophobia, photo­phobia, more pronounced; attacks separated by symptom-free intervals (distinguishes migraine from headache due to brain tumor)

Primary headache disorder: neurologic (secondary headache disorder has other etiology, eg, fever); migraine with­out aura  —most common type (60%-80%) in children; migraine with aura  —  seen in 15% to 30%; better described as migraine spectrum disorder; includes typical migraine with migraine headache; typical aura with nonmigraine headache; typical aura without headache; childhood periodic syndromes  —  also called precursors of migraine or migraine variants; child has recurrent problems not associated with headaches, but develops migraine headaches later in life; include abdominal migraine (dull abdominal pain with no known cause), benign paroxysmal vertigo of childhood (recurrent dizziness and ataxia), and cyclic vomiting; retinal migraine  —  monocular blindness of sudden onset, lasts for few hours, then resolves; complications of migraine  —chronic migraine (occurs ³15 times/mo over 3 mo); status migrainosus (one prolonged difficult-to-resolve headache); probable migraine  —  features of migraine present but technically unable to meet criteria, usually for number of required attacks

Diagnostic criteria for migraine without aura in children: International Classification of Headache Disorders (ICHD); ³5 attacks fulfilling criteria; attacks last 1 to 72 hr; associated with ³2 of following, ie, unilateral, bilateral, or frontotemporal location (but not occipital [red flag for possible cerebellar tumor-type headache]), pulsatile qual­ity, moderate or severe pain intensity, and aggravation by routine physical activities; during headache, ³1 of follow­ing, ie, nausea or vomiting, photophobia and phonophobia; not attributed to another disorder

Diagnostic criteria for migraine with aura in children: ³2 attacks fulfilling criteria; aura consisting of ³1 of fol­lowing (but no motor weakness), ie, fully reversible visual symptoms, sensory symptoms, and dysphasic speech; ³2 of following, ie, visual symptoms or unilateral sensory symptoms; ³1 aura symptom develops gradually over ³5 min or different aura symptoms occur in succession over ³5 min and £60 min; not attributable to another disorder

Diagnostic criteria for basilar migraine: fulfills criteria for migraine with aura; pain possibly occipital in location; ³2 of following, ie, dysarthria, tinnitus, impaired hearing, and diplopia

Familial hemiplegic migraine: uncommon; genetic (autosomal dominant); appears similar to stroke, with hemipare­sis and dysarthria; frequently, hemiparesis on opposite side of headache pain; in sporadic type, patients to have no family history; benign paroxysmal torticollis  —  linked to migraine; usually starts in infancy; rare; recurrent and gradually resolves over time; potential precursor to basilar migraine (also benign paroxysmal vertigo)

History: each set of criteria has commonality (not attributed to another disorder); must eliminate other causes of headaches; red flags  —  negative family history of migraine; change in type of headache (migraine headaches usu­ally similar from episode to episode); abnormal findings on neurologic examination; family history  —  positive in 80% to 90% of cases; headaches in family members possibly resolved or attributed to other causes; must be persis­tent and meticulous; look for associations, eg, motion or travel sickness, colic as infant, sensitive scalp, and sleep disturbances; study  —  found that children with migraine experienced more sleep disturbances, compared to healthy norms; target sleep hygiene as part of biobehavioral treatment; most commonly described triggers  —  fatigue, miss­ing meals, certain foods, and trauma; parental observations (eg, grabbing head, covering eyes or ears) help establish severity and location of pain, and presence of autonomic symptoms

Diet factor: diet as trigger and diet modification as treatment frequently overlooked; complex to study because mul­tifactorial; most common triggers in children  —  cheese, chocolate, and citrus fruits (alcohol in adolescents); also caffeine (intake or withdrawal), monosodium glutamate, and aspartame

Physical examination: vital signs, including BP (especially in throbbing-type headache, looking for secondary cause of headache); child with disturbance in growth may have secondary cause of headache; optic fundi in all children, especially teens (rule out benign intracranial hypertension); perform thorough neurologic examination, including cerebellum and cranial nerves

Pathophysiology: primary neuronal process; associated with genetically determined hyperexcitable cerebral cortex; disturbances in calcium channels lead to lowered threshold for external and internal triggers; triggers begin slow wave of cortical spreading depression (CSD); CSD causes hyperpolarization, followed by depolarization, causing hypoperfusion (responsible for symptoms and aura); trigeminal vascular system activated, leading to vasodilatation responsible for throbbing pulsatile component of headache; inflammatory substances released, creating neurogenic inflammation and pain; hypersensitization results, causing normal stimulation, eg, brushing hair, to be perceived as pain (allodynia; indication of progression of headache and tied to efficacy of treatment)

Practice parameter for children with recurrent headaches: for children 3 to 18 yr of age; headaches unassociated with trauma, fever, or other provocative causes; evidence-based; neuroimaging  —  not indicated in children with normal neurologic examination (migraine without aura); in children with migraines with aura and unusual neuro­logic manifestations; consider neuroimaging in presence of focal findings, signs of increased ICP, alteration of con­sciousness, and coexistence of seizures; consider imaging with historical features of recent onset of severe headache, change in type of headache, and associated features that suggest neurologic dysfunction

Treatment: acute therapy  —  early analgesic use (instruct parents to give analgesic at first indication of headache); use therapeutic doses; avoid narcotics (cause rebound headache); hydration; biobehavioral therapy  —  avoidance of triggers; sleep; preventive therapy

Pharmacologic agents: ibuprofen  —  safe and effective; dose 10 mg/kg; acetaminophen  —  more effective than pla­cebo at dose of 15 mg/kg; neither acetaminophen nor ibuprofen prevent recurrence; triptans  —  effective but not for allodynia; less effective for status migrainosus; sumatriptan  —  nasal spray; subcutaneous route not well studied; oral triptans not found effective in most studies; prochlorperazine  —  effective in children; frequently used with hy­dration; effective when given intravenously (IV); diphenhydramine given as pretreatment to prevent extrapyramidal side effects; other agents  —  metoclopramide; oral dihydroergotamine ineffective and causes vomiting, necessitat­ing antiemetics; IV dihydroergotamine effective; opiates cause rebound headaches; dexamethasone  —  no studies in children; effective in preventing headache recurrence in one study of adults; believed to reduce neurogenic inflam­mation

Analgesic overuse headache: when analgesics used  more often than 2 to 3 times/wk; often, stopping analgesics and using biobehavioral therapy more acceptable option

Prevention of migraine: flunarizine (not available in United States); cyproheptadine; topiramate

Suggested Reading

Atabaki SM et al: A clinical decision rule for cranial computed tomography in minor pediatric head trauma. Arch Pediatr Ado­lesc Med 162:439, 2008; Crawford P et al: Clinical inquiries. What dietary modifications are indicated for migraines? J Fam Pract 55:62, 2006; Damen L et al: Symptomatic treatment of migraine in children: a systematic review of medication trials. Pe­diatrics 116:e295, 2005; Dunning J et al: Children's head injury algorithm for the prediction of important clinical events study group. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head in­jury in children. Arch Dis Child 91:885, 2006; Hershey AD: Adolescents with migraine: nature vs nurture. Neurology 69:12, 2003; Lewis D et al: American Academy of Neurology Quality Standards Subcommittee; Practice Committee of the Child Neu­rology Society. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology 63:2215, 2004; Lipton RB et al: AMPP Advisory Group. Migraine prevalence, disease burden, and the need for pre­ventive therapy. Neurology 68:343, 2007; Marcovitch H: Managing minor head injury in children. BMJ 333:455 2006; Mun­son S et al: The role of functional neuroimaging in pediatric brain injury. 117:1372, 2006; Strine TW et al: The associations among childhood headaches, emotional and behavioral difficulties, and health care use. Pediatrics 117:1728, 2006.