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Case 20
7-YEAR-OLD WITH HEADACHES - NICHOLAS
Author: Mary Moran, M.D., MCP Hahnemann School of Medicine
Learning Objectives
1. List key features in the history of a child with headaches.
2. List the elements of a thorough neurologic exam and interpret
abnormalities.
3. Discuss the differential diagnosis of headaches in children.
4. Discuss the differential diagnosis of ataxia in children.
5. Identify signs and symptoms of increased intracranial pressure.
6. List things to consider when conveying difficult news to a patient and family.
Summary of clinical scenario: Seven-year-old Nick is in the clinic because his
headaches, which he has had monthly for a year, are increasing in frequency. The
history reveals that his mother suffers from migraines and that Nick's mother and
father have recently separated. Ten days after the initial visit, Nick returns with
increasingly frequent and severe headaches and additional signs and symptoms
that include papilledema, horizontal nystagmus to the left, an ataxic gait, left leg
hyporeflexia and hypotonia, and a positive Romberg test. He is diagnosed with a
left-sided cerebellar tumor.
First network:
Family history of migraines
Headaches for one year
Stress at home and school
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First network:
Normal neurological exam
No papilledema
Second network:
Ataxia
Papilledema
Left nystagmus
Past-pointing
First network:
Migraine
Tension headache
Stress reaction
Brain tumor
Differential Diagnosis
Sinusitis
Second network:
Brain tumor
Toxin
Basilar artery migraine
Final Diagnosis
Cerebellar tumor
Case highlights: The students create an initial differential for the headaches, a
second differential for the new symptoms, and learn the diagnosis is a cerebellar
tumor. The case demonstrates how to deliver bad news to the patient and his
parents. Multimedia features include: MRI showing the tumor; photo of normal
optic nerve and fundus; photo of papilledema; video of a patient with nystagmus;
photo of a boy rubbing his nose in an allergic salute.
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Brain tumors:
Epidemiology
Most common solid tumor in children
Male incidence slightly higher than female
Second most common form of childhood cancer (behind leukemia)
Incidence is increasing for unknown reasons
Risk factors
Exposure to ionizing radiation
Certain genetic syndromes, such as:
Tuberous sclerosis
Neurofibromatosis
Li-Fraumeni syndrome
Symptoms
Infratentorial lesions: Usually present with cerebellar signs and signs of
increased intracranial pressure
Cerebellar hemispheric lesions: May see changes in muscle tone and deep
tendon reflexes; more often find hypotonia and hyporeflexia
Supratentorial lesions: Focal motor and sensory abnormalities on side
opposite the lesion
Brain stem lesions: Often associated with cranial nerve and gaze palsies
Histologic types
Primitive neuroectodermal tumor, or medulloblastoma: Most common
of all pediatric brain tumors. Malignant tumor that can spread throughout
nervous system. Capable of metastasizing to extracranial sites. Treatment
and prognosis are dependent on size and dissemination of tumor. Treatment
generally includes surgical resection, radiation, and chemotherapy.
Astrocytoma: Astrocytoma of the cerebellum has best prognosis of all
infratentorial in children. Often with cystic component. Treatment is surgical
resection, with five-year survival approximately 90% when completely
resected. Radiation reserved for those with high-grade tumors, partial
resections, or those in whom postoperative tumor progression is seen.
Brainstem glioma: May be quite aggressive, resulting in diffuse infiltration
of the pons, or low-grade, resulting in a focal tumor in the midbrain or
medulla. Prognosis ranges from grave to good. Surgical resection alone
required for low-grade gliomas.
Ependymoma: Arise from within fourth ventricle (ependymal lining). Cause
symptoms related to hydrocephalus. Treatment usually surgical resection
plus radiation. Five-year survival approximately 50%.
Complications
Deaths from brain tumors are highest among all childhood cancer deaths.
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Long-term sequelae of childhood brain tumors are most often due to effects
of chemotherapy and/or radiation therapy, including:
Neurocognitive defects
Attention deficit disorder
Learning disabilities
Endocrine abnormalities
Stroke
Headache:
Types
Tension headache:
Episodic, worsening throughout the day
Mild to moderate intensity
May feel like band around head or involve occipital area with tenderness of
posterior muscles of the neck
Occur in setting of emotional stress, fatigue, lack of sleep, and other
stressors
Migraine headache:
Most common cause of recurrent headache in children
More severe than tension, and often throbbing
May be accompanied by photophobia and/or phonophobia, abdominal pain,
nausea, vomiting
Precipitating factors include stress, bright lights, odors, and foods
Often relieved by sleep
Migraine types:
Classic: Accompanied by aura (visual symptoms, speech changes, or
other sensory abnormalities)
Common: Most frequent migraine type in children. No aura, frequently
unilateral (frontal or temporal)
Basilar artery: Uncommon migraine variant associated with bilateral
visual changes, paresthesias, and altered mental status
Migraine variants (seen exclusively in pediatric age group): Cyclical
vomiting, abdominal migraines, benign paroxysmal vertigo
Concerning symptoms
Headaches occur after a period of recumbency (e.g., early morning or after
a nap) or awaken patient from sleep
Headaches accompanied byand relieved afterforceful vomiting
Pain aggravating by bearing down (valsalva maneuvers)
Sudden onset
Headache accompanied by photophobia and fever
Headache accompanied by elevation in blood pressure, bradycardia, and
irregular respirations (Cushings triad)
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Skills
History:
Headache: Eliciting a good history is crucial in evaluating a complaint of
headache. Remember to include:
Social history:
Headache may be due to anxiety, depression, or stressors in patients
life.
Children may have somatic complaintsincluding headache that
have a psychological etiology.
Ask about childs home, family, school, and friends.
Headache history:
Character and duration of headaches
Location
Associated symptoms
Activity at time of onset
Potential triggers and alleviating factors
Physical exam:
Neurological exam
Cranial nerves and visual fields:
Test visual acuity, extra-ocular muscles, pupillary reflex, facial
sensation and facial muscle movement and symmetry, position of
uvula and tongue, symmetry and strength of sternocleidomastoid and
trapezius muscles.
Fundoscopic exam:
Look for blurring of edge of optic disc and narrowing of vessels,
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Differential diagnosis
Based on first clinic visit
1. Migraine: May occur any time of day, involve any part of the head, and is
triggered by stress. A family history of migraines is present in 50% of those
affected. The pattern is usually not progressive.
2. Tension headache: Often bilateral and involving forehead, temporal areas
or back of head. Tenderness of the posterior muscles of the neck may be
present. Generally worsen throughout the day. Stress can be a trigger.
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Studies
Magnetic resonance imaging (MRI): Provides excellent detail of the posterior
fossa. In children, frequently requires sedation.
Computed tomography (CT): Will not visualize the posterior fossa as well, but
is often easier and faster to obtain than MRI in some centers. May be valuable
when intracranial hemorrhage needs to be ruled out.
Lumbar puncture: Contraindicated in patient with signs of increased intracranial
pressure (may lead to brain herniation).
Management
Headache:
Daily headache diary: Asking patient or patients parent to keep a written log of
headachesincluding character and duration, location, associated symptoms,
activity at the time of the headache, potential triggers, and actions that relieved
the headachecan be a valuable clinical tool. The diary often includes more detail
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