Paediatric Acute care Guidelines PMH Emergency Department

Background

Headache is a common symptom in children, affecting most  children by 15 years of age.

Common Causes are:

  • Systemic illness with fever
  • Tension Headaches
  • Cluster Headaches (older children)
  • Localised ENT problems
  • Migraine +/-Aura

Uncommon but important causes:

  • Meningitis
  • Raised intracranial pressure (ICP) from tumours, bleeds etc

Risk factors

Family history of migraine predisposes to migraine

Assessment

Assess headache as either acute or recurrent:
Acute  Recurrent
  • Systemic with fever and general illness (e.g. viral illness, septicaemia, pneumonia)
  • Tension – bilateral band like pain, mild to moderate
  • Trauma
  • Sinusitis
  • Otitis media
  • Dental caries
  • Meningitis (reduced conscious level, neck stiffness, photophobia)
  • Haemorrhage (sudden onset, severe pain, reduced conscious level, neck stiffness
  • Migraine – aura, nausea, vomiting, visual disturbance, pallor, family history
  • Behavioural – consider family, school or social problems
  • Cluster – throbbing pain, possibly involving neck muscles usually unilateral and older children
  • Raised ICP – morning headaches ± vomiting, pain worse on coughing, sneezing or bending, personality changes, focal neurological symptoms 
  • Benign Intracranial Hypertension
  • Post concussion headache (days – weeks)

History

Migraine Headache
  • Migraine is a type of headache common in children
  • Appear to be familial
  • Aggravated by exercise
  • Triggers:
    • Various foods
    • Menstruation
    • Fatigue
    • Bright lights
    • Loud noises
    • Smoking
    • Drinking
    • Caffeine
  • Pain:
    • Dull or throbbing
    • Usually unilateral but can be bilateral
    • May range from mild to severe
    • Can last 1-72 hours
  • Child may also have: 
    • Loss of appetite
    • Nausea or vomiting
    • Pale
    • Lethargy
    • Abdominal Pain
  • +/-Aura:
    • May precede headache
    • Visual disturances
    • Sensory changes – pins and needles,  numbness
    • Dysphasic speech
    • Usually last 5-60 minutes
Cluster Headache
  • Older children
  • Unilateral pain – may involve eye or nasal congestion and forehead sweating
  • Lasts up to 3 hours
  • Can be daily or up to 8 times per day
  • Causes restlessnesss and agitation
  • Can be severe
Tension Headache
  • Bilateral
  • Mild – moderate severity
  • Tightening nature
  • Not aggravated by activities of daily living

 

Concerning Features

    • Headaches waking from sleep
    • Vomiting in the morning
    • Persistent visual disturbance
    • Sudden onset of headache (like being hit by a ball)
    • Motor weakness
    • Poor balance
    • ↓LOC

 

Examination

    • The child may look:
      • well
      • unwell 
      • septic
    • Full neurological assessment
    • Assess for local causes:
      • Eye
      • Sinus or ear
      • Dental
      • Cervical lymphadenopthy

 

Investigations

    • Investigations are driven by likely diagnosis:
      • Sepsis or SAH, consider LP
      • Tumour or bleed, consider CT head
      • Migraine/Tension headache – treat with appropriate analgesia

 

Management

Medications

Simple analgesia:

For all headaches –

  • Paracetamol 20mg/kg stat then 15mg/kg/dose (max dose 1g) 4-6 hourly (max dose 4g/day)
  • NSAID – Ibuprofen 10mg/kg/dose (max dose 400mg) 8 hourly
  • Aspirin 600mg-1000mg in adolescents with migraine (give at same time as paracetomol)

Migraine and cluster headaches –

  • Sumatriptan (serotonin agonist)
  • 5-20mg IN
  • 25mg orally (>12 Years)
  • Can be repeated after 30 minutes 

In severe migraine or persistent headache, consider use of Chlorpromazine Hydrochloride IV:

Administration of Chlorpromazine Hydrochloride IV:

  • Use in children > 8 years old
  • Dose: 
    • 30-50kg: Use 6.25mg in 250mL of 0.9% saline over one hour
    • > 50kg: Use 12.5mg in 500mL of 0.9%saline over one hour
  • Ampoules contain 50mg in 2mL
  • Chlorpromazine can prolong the QTc interval; this drug should be avoided in patients with cardiac disease, family history of sudden death, or potassium or magnesium deficiency (e.g. after persistent vomiting)
  • Can cause dose-dependent sedation, postural hypotension and restlessness 

Monitoring The Patient Receiving Chlorpromazine Hydrochloride IV:

  • Monitor BP, pulse and respiration every 15 minutes during the infusion and for 30 minutes after completion
  • Continuous ECG and saturation monitoring
  • Baseline neurological observations and continued hourly
  • Chlorpromazine can cause dose dependent sedation, postural hypotension and restlessness
  • Keep patient recumbent for the duration of the infusion and for 30 minutes after completion of dose

Nursing

References

  1. AMH Children’s Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2014 July. Available from: https://childrens.amh.net.au
  2. Australian Injectable Drugs Handbook, 6th Edition (online) Chlorpromazine Hydrochloride. The Society of Hospital Pharmacists of Australia. http://aidh.hcn.com.au.pklibresources.health.wa.gov.au/index.php/component/content/article/1-drug-monographs-a-z/70-section-70directory=3&itemid=8
  3. National Institute for Health and Care Excellence. Headaches: Diagnosis and Management of Headaches in Young People and Adults. Retrieved from www.nice.org.uk/guidance/cg150 on 11/08/14
  4. Kanis JM, Timm NL. Chlorpromazine for the Treatment of Migraine in a Pediatric Emergency Department. Headache: The Journal of Head and Face Pain 2014;54: 335-342 

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