The Hot Seat: Acute Headache in a 5 year-old

Hot Seat Case Unravelled (Denouement!)

by Lauren Staple

The patient was placed in ETU status, given toradol, reglan and a normal saline bolus which helped with his headache.  He also had a non-contrast head CT which was negative.  When he felt better in about an hour or two, he and his parents requested to go home.  He was told to keep a headache diary and return to headache clinic with Neurology.  The patient left with a diagnosis of headache/migraine with aura. Interestingly, he returned 3 days later as a medical alert with focal seizures.  He had right upper extremity jerking associated with staring spells and rightward eye deviation for the first time, lasting 20 minutes.  His parents reported that he was not responding to questions and was mumbling incoherent words.  Parents said he had intermittent headaches since discharge from ETU.  He remained afebrile and nontoxic in appearance.
He was given ativan and the seizure ceased in the code room.  He had a CBC and CMP with Mg and Phos which were unremarkable.  He also had an LP which was negative and was admitted to Neurology for new onset seizures.  
During his inpatient stay, he had an MRI of the brain which showed "possible small focus of cortical dysplasia within the left precentral gyrus [with an] otherwise normal brain."  He was started on acyclovir until the HSV PCR from the CSF came back normal.
Patient was discharged on Trileptal 150 mg BID [10 mg/kg/d] and will be titrated up to 300 mg BID as an outpatient with close Neurology follow-up.

Here's what how the audience responded to the questions:

"Would you order a head CT?"

"If you chose to CT and it was negative, would you perform an LP?"

"Does this child meet criteria for migraine?" 

Thanks to Emily, the week's teaching attending and to Lauren for the case. Thanks all for participating. Comments? Leave them below. Come back next Tuesday for our next case.

Teaching attending response to this week's case

by Emily Willner

The presentation of acute, severe headache in any person should raise the question of an acute intracranial process. The differential is broad and would include mass, AVM with (or possibly without) bleeding, TBI, intracranial hemorrhage from other cause, increased ICP, encephalitis, meningitis, or relatively more benign conditions such as migraine. Careful history and physical exam will be essential to differentiate between these.

In this patient’s history, several features help narrow the differential and frame my thoughts for his ED evaluation.

1) Prominence of vomiting, and association with standing. Vomiting is common with many intracranial processes, from migraine to tumor. The interesting aspect of this case is the vomiting associated with position change. This makes me concerned for a posterior fossa/cerebellar process, as emesis associated with position change may be the presentation of vertigo in a child too young to verbalize this sensation. However, there are no nystagmus or ataxia noted on exam here. I would be sure to do a seated exam for truncal ataxia (if he’s too nauseous to stand) and attempt finer to nose testing for dysmetria in this child.  

2) Visual complaints, which are unusual in a child in this age. While aura in migraine can involve a variety of visual phenomena (including visual field defects and scotomata), these most often precede the headache and begin to resolve with onset of pain. Also, aura is much less common in younger children with migraine than in older children and adults. This child’s visual symptoms may be related to migraine with aura, but it also makes me concerned for increased ICP, an occipital process, or less likely, a symptom of a partial seizure.

My plan:

I would get a noncontrast head CT in this patient, due to the acute severe headache, the vomiting (possibly vertiginous symptom?), and the unusual complaint of persistent visual disturbance.  While I try to avoid these in many patients presenting with headaches, this patient’s age and symptoms require ruling out mass, increased ICP, AVM, or other acute bleed.

I would give fluids and antiemetics (ondansetron) until I had results of head imaging. I would also check a CBC and BMP.

If the CT is positive- proceed as dictated by findings.

If CT is negative, I would try toradol in addition to fluids, and consider metaclopramide (though I don’t really like it in young kids due to increased risk of dystonic reaction). Unless he failed to improve with those therapies or became febrile or altered, I would defer an LP. If infectious, his picture sounds more consistent with encephalitis or Lyme, than a bacterial meningitis.

If the CT is negative, particularly if he improves with treatment of pain and nausea, this could certainly represent a first migraine episode. The prevalence of migraine in young children is 3-5%, and is more common in boys than girls in younger children. In addition, his mother has migraines. I would be certain to check that his visual disturbances had cleared and that a repeat neuro exam was normal before calling this a probable first migraine and sending home with Neurology Headache clinic follow up.

Here are the International Headache Society ICHD-2guidelines for diagnosis of migraine with aura.

Hot Seat Case

by Lauren Staple

5 YO M with PMH of asthma presents with an acute onset of headache associated with blurry vision and a green spot centrally. 2 episodes of emesis, associated with standing. He received motrin at home and felt better. No fevers, rashes, neck stiffness, head trauma, seizure-like activity, weight loss or night sweats, photophobia or phonophobia. He has been trying to drink but can't keep anything down.

FHx: mom with migraines, maternal GF with hx of CVA (updated)
PE:
awake and alert in NAD but vomited immediately upon standing
VS: 36.1 HR 104 RR 20 BP 126/74 O2 sat 100% RA  Wt: 28.5kg
Non-focal neuro exam in addition to a normal head-to-toe assessment

What do you think?
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