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M. Gómez de Pablos Romero*, M. Sánchez Martín**
*Residente de Pediatría del Hospital Universitario de Móstoles. **Residente de Pediatría del Hospital Universitario La Paz.
16. Headache: outpatient visit
Doctor: Good morning, I’m Dr. Jones, please have a seat.
Mother: Good morning Dr. Jones. I’ve brought my daughter Lucy because for the past couple of months she has been complaining frequently of intense headaches.
Doctor: Ok, Lucy, how old are you?
Lucy: I’m thirteen years old.
Doctor: Very well, so tell me about your headaches: when did they start? How many times a month do you have them? How long do they last each time?
Lucy: Well, for the last couple of months I’ve had headaches for at least once a week and they last for about two-three days each time.
Doctor: OK, where would you say it hurts? Is it the whole head or only part of it? And what is the pain like? Is it throbbing (like if a hammer was hitting you) or squeezing (like a tight band around the head)?
Lucy: Sometimes only one side of my head hurts, especially the front, and sometimes my whole head. I would say the pain is like a hammer.
Doctor: Do you have any other symptoms when the headache appears? Tummy ache, nausea, dizziness, vomiting? Do you see flashing lights, blurry, black or anything unusual at all before the headache starts? Do you have a tingling sensation or weakness anywhere in your body? Does light or noise bother you?
Lucy: Well, sometimes I have tummy ache and nausea, but I have never vomited. Light and noise do bother me, so normally I have to go to a quiet and dark place. I have never seen anything unusual or had a tingling sensation or weakness.
Doctor: All right. Does that help to control the headache? Do you take any medication?
Mother: Yes, normally I give Lucy acetaminophen or ibuprofen and she goes to sleep. Usually she feels much better when she wakes up.
Doctor: Right. Lucy, has the headache ever wakened you up at night? When does it usually start? At morning, at the end of the day… Are you doing anything specific when the headache appears, like physical education, or would you say that the headache gets worse with certain movements?
Lucy: No, it has never wakened me up. Sometimes it starts when I’m at school or when I’m studying at home, but not with exercise or specific movements.
Doctor: Are you taking any exams at the moment or would you say that you are stressed about something or more anxious than usual?
Lucy: Yes, we have final exams at the moment and I want to get good grades.
Mother: Lucy is a very good student.
Doctor: Excellent! So tell me a bit more about Lucy: is she a healthy girl? Does she have any illnesses? Does she take any medication? Did she achieve growth milestones normally?
Mother: When she was little she was diagnosed with cyclic vomiting syndrome, but that resolved itself several years ago. Apart from that she is a healthy girl and she has been growing up fine, she doesn’t take any medication.
Doctor: What about the family? Any important illnesses? Does anyone suffer from migraine or headaches or any other neurological disease such as epilepsy?
Mother: Well, I have headaches every now and then. The rest of our family is fine as far as I know.
Doctor: OK, let’s take a look at Lucy.
PHYSICAL EXAMINATION:
Vital signs: Heart rate: 80 bpm. Blood pressure: 120/75 mmHg. Good general condition. Well nourished and hydrated. Normal skin without any lesions. Normal cardiac and pulmonary auscultation. HEENT: Normal appearance of head and face, no macrocephaly. Abdomen: soft, nontender to palpation. No masses. Neurological examination: awake, alert, and fully orientated. Pupils equal, round and reactive to light and accommodation, no relative afferent pupil defect. Normal cranial nerve examination, muscle strength 5/5 throughout, tone within normal limits, symmetric normal deep tendon reflexes, normal sensory testing. No dysmetria or dysdiadochokinesia, no Romberg, normal gait. Direct ophtalmoscopy: no papilledema.
Doctor: Lucy’s physical and neurological examination are completely normal and there are no alarming signs. From what you’ve told me I think that the most probable diagnosis is a migraine. Migraine is the most common type of headache in children and adolescents. It is characterized by recurrent episodes of head pain moderate to severe in intensity, lasting 2 to 72 hours if not treated, typically with focal throbbing pain that worsens with activity and gets better with rest and sleep. It may be triggered by mental stress, certain foods, odors, bright lights, noise, lack of sleep, menstruation, and strenuous activity. It is usually accompanied by nausea, vomiting, light sensitivity or photophobia and sound sensitivity or phonophobia. Sometimes the headache is preceded by an aura which consists in prodromal symptoms such as visual, sensory or speech deficits but this is less common. Migraine normally has a positive family history and cyclic vomiting syndrome has been described as a precursor of migraine.
Mother: Oh, OK, so there is nothing to worry about then? Is there any treatment? Does she need any tests?
Doctor: No, it is nothing serious but it is a chronic medical condition. As the clinical diagnosis is clear and there are no alarming signs there is no need for further testing at the moment. The best treatment is prevention with lifestyle measures such as good sleep hygiene, routine meal schedules, regular exercise, adequate fluid intake, and avoidance of migraine triggers. To identify these it is useful to complete a headache diary or calendar. As soon as the headache appears she should take analgesics such as acetaminophen, ibuprofen or metamizole.
In some cases in which the headache is not well controlled with these measures and it affects the patient’s life quality we can give preventive treatment with drugs. At the moment this is not necessary, but we will follow her up. I would like to see her again in two months with her headache diary.
Mother and Lucy: Perfect Dr. Jones, thank you very much.
KEY WORDS:
Headache: cefalea.
Outpatient visit: consulta externa/ambulatoria.
Throbbing: pulsátil.
Squeezing: opresiva.
Tummy ache: dolor de tripa.
Dizziness: sensación de mareo.
Flashing lights: luces centelleantes (fosfenos).
Blurry vision: vision borrosa.
Tingling sensation: sensación de hormigueo (parestesias).
Weakness: debilidad.
Growth milestones: hitos del desarrollo.
Cyclic vomiting syndrome: síndrome de vómitos cíclicos.
Migraine: migraña.
Epilepsy: epilepsia.
Vital signs: signos/constantes vitales.
Pupils equal, round and reactive to light and accommodation (PERRLA): pupilas isocóricas y normorreactivas.
Relative afferent pupil defect (RAPD): defecto pupilar aferente relativo.
Deep tendon reflexes: reflejos osteotendinosos.
Dysmetria: dismetría.
Dysdiadochokinesia: disdiadococinesia.
Gait: marcha.
Direct ophthalmoscopy/ fundoscopy: oftalmoscopia directa/funduscopia.
Papilledema: papilledema.
Photophobia: fotofobia.
Phonophobia: fonofobia.
Prodromal symptoms: síntomas prodrómicos.
Lifestyle measures: medidas de estilo de vida.
Triggers: desencadenantes.
Headache diary or calendar: calendario de cefaleas.
