ALERTs - Ruggles Service Corporation



ALERTsCerebral anuerysmMeningitisEncephalitisAbscessBrain TumorSinus Venous Thrombosisage considerationsToddlers: may manifest as irritability Unusual complaint in younger childrenDifferential DiagnosisTensionMigraineCluster ENT infection (otitis, sinusitis pharyngitis, viral infection,etc)MeningitisPsychogenicSeasonal allergiesVision change- need for glassesBrain tumorPseudotumorHypertensionToxins (Carbon monoxide, medications, drugs)Head traumaCNS bleedDepressionOral (Dental abscess, Temporomandibular joint strain)EvaluationHISTORYGeneral health, fever, poor PO (meningitis)Mental status (encephalitis)Nasal discharge, tooth pain (sinusitis, dental infection)Abrupt onset, extreme pain (ruptured AVM, subarachnoid)Frequency and duration (steadily worsening more concerning)Timing and circumstances (present on waking or awakening from sleep raises concern for tumor), tension headaches occur most frequently during the school day (tension)History of traumaAura, relationship to food ingestion (migraines)Associated vomitingPHYSICAL EXAMGeneral appearance: sick or well?Blood pressureMeningeal signsHead and neck examComplete neurologic exam including fundoscopic exam: are there any focal findings, such as ataxia, hemiparesis, papilledemaVisionConcerning findingBrain tumor red flags: nocturnal headache or pain on arising in the morning, worsening over time, associated with vomiting, behavioral changes, polydipsia/ polyuria, history of neurologic deficits (clumsiness, diplopia, et).Occipital pain: concern for posterior fossa tumors (studies have found to be statistically significant). Migraine can be associated with nausea and vomiting.Some children with migraines may develop focal neurologic findings as a part of their migraine syndromeAcute recurrent pattern with symptom free intervals can be seen with migraine, tension headache, cluster headache, neuralgias.Toddlers cannot communicate headache, but symptoms may consist of irritable, vomiting, photophobia Diagnostics testShould not be needed for routine headacheConsider transfer if LP or CT is needed for diagnosisMANAGEMENTTransfer/Admit considerationsConsider if meningitis, aneurysm, psuedotumor, brain tumor or increased ICP are being consideredREFERRALNeurology: chronic headaches, unclear etiology, focal neurologic deficitsOphthalmologyTension HeadacheTreatmentBenign: Tylenol, ibuprofenDischarge CriteriaPain controlled with PO medicationsAble to tolerate POFollow UpPrimary care physicianEncourage fluidsPrognosisVery goodAnticipatory GuidanceTreat early when headache startsReturn if looks ills, worsening, stiff neck, vomiting, feverMigraineConsider if this is in the scope of practice for your urgent careTreatmentAnalgesics (Tylenol, Ibuprofen, Ketorolac), Antiemetics (Reglan, Compazine, Zofran), Antimigraine (Sumatriptan, Ergotamines)Lower lights and decrease noise levelDischarge CriteriaPain controlled with PO medicationsAble to tolerate POFollow UpPrimary care physicianEncourage fluidsMedications as indicated Avoid stimuli (for migraines, stress, fatigue, anxiety, known food triggers)PrognosisGenerally very goodMigraine: 50% undergo spontaneous remission, as adults 5-10% of men and 10-20% of women have migrainesAnticipatory GuidanceReturn if headache is not controlled with po meds,looks ills, worsening, stiff neck, vomiting, feverEncourage sleepPsuedotumorConsider if this is in the scope of practice for your Urgent CareMANAGEMENTLP with opening pressureCSF removalREFERENCESFleisher G, Ludwig S, Henretig R, eds. Textbook of Pediatric Emergency Medicine. 5th Edition. Philadelphia, PA: Lippincott, 2006.Lewis D, Qureshi F. Acute Headache in Children and Adolescents Presenting to the Emergency Department. Headache 2000: 200-203.Haslam RH. Headaches. In: Nelson Textbook of Pediatrics. 17th Edition. Philadelphia, PA: Saunders Elsevier, 2004.Uptodate: ................
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