Headaches and Eye Exams

/in /by

Certain types of headaches need to be evaluated quickly by your pediatrician. These include headaches that are severe and have not been experienced before, headaches that are increasing in frequency and severity and causing alteration in daily activities, headaches associated with nausea or vomiting without a prior history of similar headaches and those headaches with a morning pattern that wake a child during the night. For other types of headaches that do not have any of the above features schedule a non-urgent visit with your pediatrician to obtain a thorough history, including a family history review, and perform a comprehensive physical examination. A subsequent visit to an ophthalmologist to look for any eye problems may be arranged but is not always needed if there are no vision complaints and the routine eye examination done in your pediatrician’s office is normal.

If your child sees the ophthalmologist their vision and refraction will be tested as well as eye alignment to look for any strabismus. Some types of strabismus, particularly convergence insufficiency, can cause eye strain with reading. A slit lamp examination will also be done to look for uveitis, ocular inflammation, glaucoma and other causes of referred pain that comes from the eye but is referred to the head.

While performing the examination the ophthalmologist will looks at the optic nerve and retina for changes due to increased intracranial pressure, hypertension and diabetes that could be related to head pain.

In children it is uncommon to find any of the above problems. The next step is always to return to your pediatrician to seek further specialty advice from a pediatric neurologist if the headaches continue. If possible it is always best to see a pediatric ophthalmologist or an ophthalmologist who has been trained specifically in the care of children.

Top 10 Headache Causes

/in /by

1. Foods can trigger headaches. These include foods with nitrates such as hot dogs and prepared meats. MSG can also cause headaches. Alcohol containing drinks including red wine and rum can cause headaches and the sudden withdrawal from caffeine containing drinks can trigger headaches.

2. Weather changes including extreme temperatures, changing temperature, barometric pressure or humidity and sudden weather changes can cause headaches

3. Sudden or prolonged exposure to the sun, flickering or shimmering light, glares and reflected light can set off headaches. Loud noises and certain smells can trigger a headache. When these triggers occur concurrently you are at the highest risk.

4. Make sure you are properly hydrated. This is a major problem during the summer months and even during the school year when children consume less water so they do not need to use the bathroom. If your urine is not almost colorless throughout the day you are at risk for causing a headache.

5. Be cautious with the timing and amount of exercise you engage in. Sudden strenuous exercise can set off strain induced exertional headaches.

6. Don’t get caught off guard and forget to take ibuprofen with you. If you feel a headache starting it is important to take your medication as early as possible and give it time to work. If you are on specific medication to halt the progression of a headache always carry it with you.

7. Use a liquid or gel preparation of ibuprofen. It gets into your system faster and stops a headache before it progresses to a point of no return.

8. Rest and relaxation or sleep in a cool, quiet and dark room can often help resolve an oncoming headache.

9. Do not overuse pain medication. Overuse of pain medication such as ibuprofen or acetaminophen can bring on rebound headaches. Keep their use to less than 1 dose per week.

10. Stress can cause headaches. Learn some relaxation techniques including breathing exercises or guided positive imagery and progressive relaxation techniques. Breathe in through your nose to a count of 4 and then breathe out through your mouth to a count of 8. Do 4 cycles and see how much better you feel.

Headache 101

/in /by

The first line medication for headaches include amitriptyline or nortriptyline or antiepileptic drugs such as topiramate (Topomax) or valproic acid (Depakote). If the episodes are infrequent and occur less than 4-5 times per moth an abortive plan using a triptan medication is often best.

As always the focus should be on identification and elimination of triggers rather than using chronic preventative medication called prophylaxis. Migraine sufferers are generally more sensitive to various triggers including bright light, sounds and smells. These sensations can not only trigger a headache but make an ongoing headache worse. Stress reduction techniques and a holistic lifestyle that focuses on a consistent and appropriate sleep, an active lifestyle and a healthy diet remain the prime focus to eliminate headaches.

Cluster headaches are more common than chronic paroxysmal hemicranias (CPH) which are quite brief and can occur several times or more per day. CPH responds to indomethacin and cluster headaches do not. Cluster headache suffers often report alcohol is a trigger and frequently are exposed to smoke. Exposure to second hand smoke can trigger headaches. Nicotine which is one of the compounds found in smoke has blood vessel effects that may be involved with this causation.

Chronic headaches occur daily and tend not to have the GI and light or sound sensitivity and are more dull, begin in the morning and increase throughout the day. They are often seen with the overuse of abortive medication which if overused cause rebound headaches. A headache diary for triggers and patterns, an active lifestyle and a healthy diet that avoids caffeine, MSG and Nutrasweet can help. Remember, caffeine can help decrease headaches when used infrequently. Frequent caffeine ingestion can trigger rebound headaches.

Muscle strain and overuse especially in the neck and shoulder regions can cause headaches. Neck spasms in young children may be due to a sudden increase in certain repetitive activities or due to minor neck injuries. Local measures and patience usually are best. In adults with arthritis or disc problems other interventions or trigger point injections may be necessary to ease cervicogenic headaches. Over 50% of adolescents with migraine or tension headaches experience neck and shoulder pain with a headache.

The key with headache treatment is to keep multiple treatment options at hand, find the best way to deliver the treatment and find what is best for you or your child.

Migraine Management

/in /by

The most important step in migraine management is to keep an accurate diary and drawings of the migraine episodes. Information that needs to be included in the diary is outlined in another blog entry. Since the diary will be completed during the headache it will be written by a parent. There should be at least six lines for each headache and it should be written in narrative form as if you were writing a newspaper article. In general answers need to be provided to the W’s: when, what, where, who and why. The child or teen can make of drawing of the headache after the headache has improved.

Look for triggers and patterns. Avoid any dietary or lifestyle triggers. Your child needs a healthy lifestyle in terms of sleep, activity and dietary intake. If your child is not getting 8-10 hours of sleep a night and their sleep schedule is not consistent 7 days a week then make changes. Sleeping in on weekends and fatigue in the am requiring assistance to wake up need to be eliminated. The same sleep and wake schedule should be followed 7 days a week. Too much or too little activity and exercise will set off a migraine. A healthy balanced diet is essential and breakfast is as important as everyone says.

Try to recognize signs that a headache is coming. These are called premonitory signs and can allow you to recognize and treat a headache early. You must treat a migraine early and aggressively to have success. Waiting until there is superficial facial pain (cutaneous allodynia) decreases response from 90% to 40-50%.

Migraine Headaches

/in /by

Headaches are seen in 10% of younger children and up to 30% of teens. Most headaches are mild and do not limit activity. Recurrent headaches are often migraines and are frequently under recognized and under treated. Migraine headaches can be stressful to children and their families and cause school absences.

Migraines are inherited and are associated with focal dysfunction of the brain. They are a complex condition involving dysfunction of the brain, the autonomic nervous system, cranial nerves and cranial vessels. Distant organ systems including the gastrointestinal system are often involved.

Recurrent headaches are worrisome if the child is under age 5 years or if there is no family history of migraine headaches. If there is no extended history of headaches or if there are mental status changes associated with the headaches concern should be raised. Other warning signs include pain during exercise or a history of trauma to the head or neck. If there is fever or signs of neck stiffness there is also concern.

Substance abuse, toxins, pregnancy and various medications can also cause recurrent headaches.

Migraines in children last from 1hour to 2 days. The pain is often on one or both sides of the front and side of the head. It often is pulsating, moderate to severe in intensity and aggravated by physical activity. During the headache at least one of the following is present: nausea and/or vomiting or noise and/or light sensitivity.

Children can also have migraines with an aura. An aura warns of a coming headache. It may be visual or consist of numerous sensory changes. It usually lasts minutes to less than one hour and pain follows the aura. Common non head pain migraine symptoms include nausea, vomiting, diarrhea, dizziness, light or noise sensitivity, vertigo, chills, sweats and hives.

Many chronic and recurrent headaches are not migraines and are due to medication overuse. Caffeine withdrawal is another common cause.

Neuroimaging is recommended if the headache is of new onset and there is a history of trauma or no family history of migraine. If your child’s neurological exam is not normal or if seizures occur an MRI needs to be obtained. An MRI is preferable unless there is an immediate concern of trauma as the cause.

The goal of treatment is to reduce headache frequency, intensity and duration through the use of education and lifestyle changes while using the minimum amount of medication intervention.

Headache Basics

/in /by

Children and adolescents get the same type of headaches as adults but their symptoms are often different. The criteria that are used to categorize headaches in adults are only partially successful in children. In addition, young children or children with special needs have difficulty describing and providing information. This can make headache management difficult.

Generally, headaches in children are not serious. In most cases routine headaches are caused by minor illness, fatigue, stress or anxiety. Sleep and schedule disruption area also common factors. If the cause of the headache is not clear and the headaches continue or appear to worsen you must discuss them with your pediatrician. Although most headaches can be easily treated with time, rest and over the counter medications some of the headaches children have require advice from your pediatrician or a specialist who deals with headaches in children.

The most common types of headaches are tension type headaches and migraine headaches. Tension headaches may be intermittent or chronic and can last from 30-60 minutes to several days. The pain is usually mild to moderate in intensity and does not prevent your child from being active. Most of the time, other associated symptoms including nausea, vomiting or noise and light sensitivity do not occur. There is often a description of band like pressure around the head but this history is difficult to obtain in children. Migraine headaches are similar to tension headaches. They generally are more severe and the child often describes a pounding sensation on one or both sides of the head. Pain increases with exertion and distraction is of limited help. Vision changes, nausea, vomiting and stomach pain are common associated complaints as is sensitivity to light, noise and various smells. These children may experience a warning (aura) that a headache is coming and there often is a family history of migraine headaches.

Another type of headache is chronic daily headache. This can result from taking some types of medication and can include rebound headaches from taking excessive OTC pain medication or be caused by environmental stress related factors.

The first step with all headaches is to look for a cause and identify any patterns or triggers. Emotional factors and genetic predisposition need to be considered as do any underlying medical conditions. You must keep an accurate record of the headaches. The use of a headache diary and headache drawings will be discussed with you by your pediatrician.

This information is the most important factor in developing an effective treatment plan. The next step is to develop a holistic approach involving holistic lifestyle changes while monitoring for specific triggers or patterns that bring on a headache. Special testing including brain imaging and lab tests are frequently not needed. A thorough history, physical examination and neurological examination are the fundamental interventions.

Developmental Milestones Birth to 1 Year

/in /by

Developmental milestones can be followed in the areas of gross motor, visual motor, language, adaptive and social skills. Most parenting books will give an extensive breakdown of the exact time skills are expected to emerge. There is a wide variation in
development. Some children develop smoothly throughout most of the categories while others will show spurts in certain areas while others seem to lag only to catch up soon after.

Here are some major skills you can look for in your child:

2 months: when on stomach(prone) able to hold head up and at times chest up; hands are fisted 50% of the time; alerts to voice and sounds; coos; mouth opens at sight of breast or bottle.

4 months: props self up on forearms when prone; sits with support with good head control; no head lag when pulled up to sit position from lying on back; hands are open and not fisted; will look at feet and hands; bats at toys; turns to sound; laughs; will take turns with vocal play; places mouth on everything; quiets to parent soothing or voice of parent.

6 months: rolls over from stomach to back; tripod sits with some anterior support of hands; able to push up when on stomach to hands and knees briefly; transfers objects from one hand to another; takes an object when offered; uses a raking grasp to reach for objects; makes raspberry sounds and then early babble by 6-7 months; recognizes own name; increases back and forth vocalization with caregivers; attempts to feed self with hand to mouth; onset of some stranger anxiety;smile at self in mirror.

9 Months: beginning to pull to stand and crawl; bear walk; bang blocks together; grasp
with thumb and 2 fingers; uses “mama and dada” appropriately; repeats sounds and
some words; mature sounding babble; looks for objects when they are dropped; rings a bell for fun; will look in the direction of an object being pointed at; shows anxiety when separated from parent.

12 Months: cruises and can stand without support; walks with 1 hand held; will take a few steps; uses a pincer grasp; can attain and release objects easily; points and uses gestures; will follow a simple command with a gesture; begins to feed self;  says 1 word that is not a proper name.

Development Tips: 25 to 48 Months

/in /by
  • With your child: make animals, people, etc., from pipe cleaners, string large beads, use play money.
  • Make a tent with and old curtain, sheet or blanket draped over a card table or two chairs.
  • Make puppets from old socks. Tell a story with characters.
  • Plant seeds in paper cups (lemon, orange, grapefruit seeds, grass seeds, carrot top, sweet potato, etc.).
  • Cut and paste together on a piece of cardboard scraps of old fabric.
  • Use cardboard boxes like blocks.
  • Play dress-up.
  • Dance to a favorite song on the stereo.
  • Finger paint a design on a table using shaving cream.
  • Use modeling clay or “playdoh” (get out the cookie cutters, rolling pins, silverware, etc.)
  • Blow and catch bubbles.
  • Make puppets from paper bags.
  • Give crayons and paper and let him create a picture (scribbling is important at an early age).
  • Fill the sink or dishpan with water and let your child play: provide cups, sponges, etc.
  • Read and listen to stories (books and records).
  • Sail boats in the bathtub.
  • Play store.
  • Make string or yarn designs (glue onto paper, wood, etc.).
  • Make and fly paper airplanes.
  • Make popsicle stick designs (glue them).
  • Fly a kite.
  • Make “things” with egg cartons (tulips, caterpillars, etc.)
  • Play a color game (I see something red).
  • Have a race, running on feet, knees, crawling, holding ankles, running backwards, etc.).
  • Have a pea race, blowing dried peas with a straw.
  • Make a “feel” box (cut a hole in the side of a box and put an object inside of the box; have the child tell what it is by feeling it).
  • Teach numbers and letters by cutting them out of sandpaper.
  • Make a picture dictionary (a page for each letter with pictures beginning with that letter).
  • Weigh things if you have a bathroom scale (yourselves, toys, objects).
  • Talk about time with your child (make a clock with a paper plate and hands cut from colored paper).
  • Make a counting carton (number each section of an empty egg carton, 1-12).
  • Play “Simon Says” (leader gives commands and others obey when preceded by the two words “Simon Says”).
  • Play musical chairs.
  • Imitate animal’s movements (frog, horse, fish, bird, duck, snake, spider, etc.).
  • Set up an obstacle course in the backyard (cardboard boxes, barrels, old tires, ropes, etc.).
  • Play a pantomime games (have your child act out a word such as hop, swim, comb, wash, chew, zipper book, swallow)

Development Tips: 19 to 24 Months

/in /by
  • Encourage your child to creep backwards down the stairs.
  • Hold your child’s hand while coming down the stairs. Encourage climbing stairs while holding the rail.
  • Demonstrate to your child jumping off the floor with both feet. Try jumping off a box or bottom step in front of him.
  • Practice kicking an unmoving ball.
  • Place a line on the floor and practice walking on the line.
  • Practice stacking small blocks.
  • Utilize toys that have parts that fit together (i.e., pop-beads, peg boards, stacking rings, nesting cups).
  • Play “Simon Says” with your child using easily seen motions (i.e., hands over head, clapping, stomping, swing arms).
  • Place objects in a shoe box. Then, give a matching object and ask him to find the same object in the box.
  • Ask your child to do 2 related instructions (i.e., pick up the block and put it in the cup).
  • Place 5 objects in front of the child and ask him to give you “what you name”.
  • Encourage your child to use more than 2 words at a time. When he asks for something such as milk, as him if he wants “more milk please”.
  • Encourage your child to use “me,” “you,” and “I.”
  • Assist your child in pulling pants up or down. Encourage dressing.
  • Give your child opportunities to drink from a straw.
  • Encourage your child to imitate common household activities.

 

Development Tips: 16 to 18 Months

/in /by
  • Demonstrate and assist your child in walking backwards and sideways.
  • Place his favorite toys out of reach and cheer him on as he “runs” to retrieve it.
  • Help your child to get in and out of a small chair.
  • Play “bring me” games to encourage your child to walk and carry something at the same time.
  • Hold your child’s finger around a large crayon and make strokes along the paper.
  • Wrap small toys in wax paper or use tissue and encourage your child to unwrap the toy.
  • Assist him in matching a picture of an object with the real object. Use magazine pictures or photos.
  • While dressing, point to clothing or body parts and ask “What is this?”
  • In picture books and catalogs, point to and name pictures for your child. Later on, ask him to name these and reduce assistance as you go.
  • Practice unzipping a large jacket zipper.
  • Assist in scooping with a spoon, decreasing assistance until your child is independent in eating with a spoon. Expect some spillage.
  • Make a game of trying to put shoes on during dressing (either foot is acceptable).
  • Song and activity records are enjoyable because your child can participate verbally and physically.