So, we might also might be seeing patients
with headaches and it could be a secondary
In other words, it could
be from another problem.
And we have to worry about that
One possibility is intercranial
Meningitis of course can
and typically, what is distinguishing
about that is they will have fever.
And they will be unwilling or unlikely
to be able to put their head down
and touch their chin to
Increased intercranial pressure
can cause headache.
One way to remember things that
can cause intercranial pressure
are remembering all the tissues that are
inside the skull
and what if there is more of them.
So, for example, a tumor can cause headache.
A mass of brain tissue
will expand and increase the ICP.
Typically those patients will have
and that is a key historical point.
They should be having headaches
in the morning
and also vomiting.
That happens because as they are lying
down through the course of the night,
the pressure starts to accrue.
Standing up, it is relieved
simply through drainers
through the Foramen magnum.
Other examples of fluid would be
Increased brain fluid or CSF.
This happens of course with
patients with hydrocephalus,
who can develop headache.
A patient with a shunt, who has
will usually present with headache.
Blood is also in the brain and if
it accrues as a bleed
either through trauma or a raptured
that can cause a profound headache.
and abnormal breathing.
And if we see that,
that is actually a very late
in patients with increased
So, a headache diary can help.
If the patient is coming in with
and you ask them to keep a diary
of when those headaches are happening,
and you note morning headaches,
consider a mass.
One last common cause of headaches
abusing the medicines we use
to treat headaches.
This sounds strange but it is
And it is particularly true of
NSAIDS like Ibuprofen.
If the patient is having frequent cluster
tension headaches or migraines,
and they find themselves taking a lot
it can be that the Ibuprofen
itself is causing a headache.
This can be challenging to treat because
what we need to do is actually remove
them from the Ibuprofen
and in many times have them suffer
through their baseline headaches
before those headaches will start
from the Ibuprofen chronic use.
So, there are several historical clues
that you can use
to tip you over the edge and say,
this maybe a headache
that is more substantially
something going wrong as supposed
to one of the typical headaches types.
Like I said, morning or nocturnal headaches
should absolutely be concerning to you.
As a sign for
Morning vomiting is concerning.
Severe pain at the onset of
a thunderclap headache
maybe an indicative of AVM,
But please remember in children,
it is exceptionally rare
an AVM or an aneurysm.
That is much more common in adults.
So, the worst headache of life scenario
is rarely actually an aneurysm
A fixed location or an occipital
location to a headache is usually a sign
of intercrania pathology.
Headache in a child with a
is always an emergency.
It is entirely possible that that child
can have an obstruction of their shunt.
And that child needs to be evaluated.
If the headache is particularly bad,
we'll obtain a shunt series
a series of x-rays looking at
the integrity of the shunt
and even might need to look at the size of
In the past, we use CT scans to
look at the size of the ventricles,
but now we can use a rapid MRI
in many centers
that can avoid radiation
in these patients.
If a patient has lethargy or confusion,
that is a sign that there might
be a problem
that is more substantial than just
Although do remember,
can have complicated symptoms.
Any vomiting in a setting of
is probably more than just
of course if a patient is having
a headache before a seizure,
then that may be a sign that there is
something more significantly going on
than just a headache and that there maybe
an intercranial pathology going on.
There are certain physical exam clues that
may tip you off
that this headache is something
and a specific problem is triggering
the headache as opposed to this
being a headache syndrome.
One is again that's the Cushing's triad.
Hypertension and bradycardia
that is good for a test.
But in reality these patients are very
sick before Cushing's triad shows up.
Until very late finding in
These patients will usually have
altered mental status and other things.
Papilledema is a finding that you can get
better at seeing if you practice
your fundoscopic exam.
Papilledema is a sign of
And we've seen it many times in
patients with headaches
as result of increased ICP.
Nuchal ridigity is a sign of meningitis.
And If the patient has nuchal rigidity,
you need to worry about meningitis.
Cranial nerve palsy is common
in certain conditions
that can present with headache.
The classic one on the east coast
of the United States is Lyme disease.
Patients with Lyme disease
may well have headache
or frank meningitis and they often can
present with a seventh cranial nerve palsy.
A focal neurologic exam is probably
a sign that a patient has
an intercranial pathology and requires
Ash leaf spots are an early
sign of tuberous sclerosis.
There will be another lecture about tuberous
but patients with tuberous sclerosis can
develop tubers in the brain
which could cause increased
ICP or other problems
that could be consistent with
tuberous sclerosis and this disease
Lastly, if a patient has macrocephaly,
those headaches are probably
from increased ICP.
We track head circumference in children.
But it is important for any child
who is presenting with a neurologic complaint
to have their head circumference
measured and plotted.
Any child who has an increase in
needs to be evaluated for intercranial
That's everything I have today
for you on headaches and migraines
Thanks for your attention.