Saturday, April 1, 2017

A headache story

At 9 years of age a boy with a history of a right middle cranial fossa arachnoid cyst with rupture into the subdural space resulting in subdural hygroma status post fenestration and cystoperitoneal shunt placement presented for evaluation of chronic headaches.  His prior pediatric neurologist had placed him on prophylactic therapy for headaches with topiramate.  His most recent cerebral imaging study showed a functioning cystoperitoneal shunt.  7 months later, topiramate had been increased to 100 mg bid, without evident benefit.  Amitriptyline therapy was initiated.  

6 months later, the patient was hospitalized after experiencing a headache associated with vomiting.  Topiramate was discontinued. A MRI showed a small arachnoid cyst to be present with no other abnormality.  Shortly thereafter, he was readmitted after experiencing a generalized tonic-clonic seizure.  An EEG showed diffuse background slowing, more pronounced in the right hemisphere.  Valproate therapy was initiated..  Subsequently, valproate, taken at a maximal dose of 375-375-250 mg, was discontinued.  It had not seemed to impact on the chronic headaches.  Referral for non-pharmacological headache management was recommended.

A second neurosurgeon felt that the past had developed a Chiari 1 malformation and at close to 11 years of age, a Chiari decompression was performed.  Another provider had started the patient on sertraline, which was later discontinued. Butterbur and feverfew were tried.  Amitripyline therapy was continued and incrementally advanced to a 150 mg daily dosage.  Because of headaches, school attendance was dismal.  Referrals to a pain clinic and a psychiatrist for anxiety were recommended.

When the patient was 15 years of age, full custody was given to his father.  Amitriptyline was discontinued.  In the past, the patient had been treated for attention deficit with atomoxetine and, later, with methylphenidate.  This was discontinued.  School absences ceased.  After an evaluation at 16 ½ years of age, when the patient was reported as having occasional headaches treated with ibuprofen, he was discharged from ongoing pediatric neurology care.

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