Pediatric Primary Care (115 page)

J.  Education.

1.  Know signs and symptoms and when and how to give DIASTAT AcuDIAL.

2.  Medication information and compliance.

3.  Avoidance of any seizure triggers: sleep deprivation, alcohol.

4.  Seizure safety: no tub baths unsupervised, monitor closely with swimming, helmets appropriate for sports, no driving until seizure free for 6 months, what to do during a seizure–lay on side on ground, do not put anything in mouth, time event, and keep safe.

VI.  CONFUSIONAL MIGRAINE

A.  Characterized by a typical migraine aura, headache, and confusion.

B.  Etiology.

1.  Idiopathic.

2.  Triggered by head trauma.

C.  Occurrence.

1.  Rare, only 5% of migraine patients.

2.  Single attacks are most common, multiple attacks are rare.

3.  May evolve into typical migraine episodes.

D.  Clinical manifestations.

1.  Inattention

2.  Distractibility.

E.  Physical findings.

1.  Impaired speech and motor activities.

2.  Can last 10 minutes to 20 hours.  A more profound, disturbed level of consciousness may lead to migraine stupor, which can last hours up to 5 days.

3.  Confusional state is usually followed by sleep.

F.  Diagnostic tests.

1.  Complete neurological exam.

2.  MRI and MRA to evaluate arteries within the brain.

3.  History may include family history, history of trauma, and classic symptoms.

G.  Differential diagnosis.

H.  Treatment.

1.  Sleep.

2.  Typical migraine-abortive medications.

I.  Follow up.

1.  Reoccurrence of episodes.

2.  Change in neurological status (resulting from any head trauma).

J.  Education.

1.  Avoidance of migraine triggers.

2.  Keep a headache/episode diary.

3.  Limit use of over-the-counter analgesics.

4.  Keep a regular schedule: meals, sleep, hydration, exercise, and minimize stress.

VII.  HEADACHES: MIGRAINES

A.  Episodic headache disorder characterized by various combinations of neurological, gastrointestinal, psychophysiological, and autonomic changes.

B.  Etiology.

1.  Generally inherited disorder, 70-80% familial.

2.  Leading hypothesis for origin–neurovascular disturbance triggered by multiple stimuli and affecting serotonin transmission in the CNS.

3.  Episodic brain malfunction–a central nervous system disorder of primarily the brain and nerves, and secondarily of the blood vessels.  Malfunction is caused in part by changes in the level of circulating neurotransmitters and involving serotonin in particular.

4.  Head trauma.

5.  Illness and infection.

6.  Environmental and emotional factors.

7.  Certain foods and beverages.

C.  Occurrence.

1.  Mean age of onset is 7.2 years for boys and 10.9 years for girls.

2.  3% of children age 3-7 years.

3.  4-11% for children age 7-11 years.

4.  8-23% for children age 11-15+ years.

5.  Risk factors:

a.  Children who have a family history of headaches or migraines.

b.  Boys before they reach puberty.

c.  Girls after they reach puberty.

d.  Children over age 10 years.

D.  Clinical manifestations.

1.  Pounding or throbbing head pain. In children, pain usually affects the front or both sides of the head. In adolescents, pain usually affects one side of head.

2.  Pallor or paleness of skin.

3.  Irritability.

4.  Phonophobia or sensitivity to sound.

5.  Photophobia or sensitivity to light.

6.  Loss of appetite.

7.  Nausea and/or vomiting, abdominal pain.

8.  Dizziness.

E.  Physical findings.

1.  May have none if not experiencing migraine at time of exam.

2.  Due to pain, may see increase in heart rate or blood pressure.

3.  Look of discomfort in facial expressions and demeanor.

4.  Wanting to lie down in quiet, dark room.

F.  Diagnostic tests.

1.  Most important aspect of diagnosing migraine is the headache history.

a.  Description of current and previous headaches, when started.

b.  Headache frequency, duration, and associated symptoms.

c.  What medications have been taken and are currently being taken.

d.  Family and medical history.

e.  Pain location, quality, and severity–how disabling?

f.  Social history–psychological symptoms.

g.  Precipitating factors.

2.  Complete neurological exam–including fundoscopic exam to rule out papilledema.

3.  Head CT.

a.  Recent/new onset.

b.  Evolution or change in headaches.

4.  Head MRI.

a.  Papilledema present.

b.  Focal neurological signs–abnormal exam, hemiparesis.

c.  Complicated migraine–examine blood vessels that supply the brain.

5.  Evaluation as needed if concern for infectious cause.

a.  LP if concern for increased intracranial pressure/papilledema present; generally need to do head MRI prior to LP.

G.  Differential diagnosis.

H.  Treatment.

1.  Treat underlying pathology if present.

a.  Diamox for pseudotumor cerebri.

2.  Goals of treatment.

a.  Reduce attack frequency, severity, and duration.

b.  Improve responsiveness to treatment of acute attacks.

c.  Improve function, reduce disability, and improve quality of life.

3.  Nonpharmacologic treatments.

a.  Relaxation techniques, biofeedback, stress management.

b.  Rest, quiet dark room, applying ice packs to forehead or neck.

c.  Lifestyle/behavioral interventions.

•  Maintain routine sleep pattern with adequate sleep hours.

•  Regular routines, meal, exercise, school attendance.