So I feel like we have comprehensively covered pediatric migraine in my previous posts. Let’s look at a few case studies to see migraine management in action in primary care, looking at a variety of typical patients with migraine over the years, childhood to young adolescent to start. I will present 3 patients to consider and in the next post, will discuss your possible interventions.
Case Study #1: Sally is an 8 year-old little girl who you have known since birth. She’s happy and friendly, loves to play soccer and school, especially math. She met all of her developmental milestones, though you do remember that she did have colic as an infant. Over the years her parents have heard her complain at times about having a headache but not often, usually associated with a long busy day or not getting enough sleep. There are many people with headaches in the family, so her complaints did not really concern her parents. They would occasionally give her a dose of Tylenol with resolution of the headache. Recently, Sally has been more vocal about her headaches, crying at times, complaining of nausea and light sensitivity with her headaches. Her mother has brought her in today to talk about this.
Your visit: Sally is her usual happy self, but her mother is a bit concerned. They report that for the past 3-4 months, Sally is having headaches about 1-2 times/month, with head pain rated 6-8/10 FACES scale, and accompanied by some nausea but no vomiting and light sensitivity. At times the headaches are preceded by eating a chocolate, occur on a hot day when Sally may not have had enough to drink or did not have enough sleep. She does not have any aura or prodrome symptoms, but her mother notices that she seems droopy and pale before and during the headache. Sally usually receives a dose of Tylenol and a drink, and then takes a nap for a few hours, which resolves the headache. You confirm that Sally has been well in the past few months, no illnesses or head trauma, and confirm the family history of migraine headache. There is nothing concerning on her physical exam.
Case Study #2: Charlie is a 10 year-old boy, known to you for a few years. He is generally healthy, met all his milestones appropriately, and is active playing a variety of sports. He attends school regularly, no learning issues, and has lots of friends. Lately he has been complaining of abdominal pain, with and without nausea, and not associated with food or diarrhea or constipation. It has been happening at school and he has had to be dismissed home multiple times in the past several weeks. The family is puzzled, as the pain is not consistently triggered by anything they can think of, no vomiting or diarrhea. They are wondering if there is something going on at school, if the pain is real and what is causing it.
Your visit: Charlie is here with his mother and father today, and they all look worried. Charlie reports that ‘out of the blue’ he starts feeling sick to his stomach, and then he gets really bad belly pain, ‘right in the middle’. This has been happening several times/week now for the past month, usually at school or in the evening. Sometimes he gets the pain without feeling nauseous. The pain is so bad that he wants to go home, and he rates it between 8-20/10 on the pain numeric rating scale. They have noticed that he becomes very pale with dark circles under his eyes with the belly pain, gets clammy and tired, just wants to sleep. After he naps for 1-2 hours, the pain goes away, but he does feel tired and sleepy afterwards. There does not seem to be anything that triggers the pain and there are no other signs of illness, no diarrhea, or headache. He has regular soft bowel movements every day, no soiling or constipation. When he does not have pain, he feels just fine, playful and happy. They do notice that sometimes the pain happens after a very long day of activity, when he has not had enough to drink, or after they eat Chinese food. They have not tried any OTC medications, thinking it would make him throw up, which he really hates. There is no history of migraine in the family that they know of. But Charlie’s father remembers that his big brother used to get really bad stomach pain when he was a kid, and he outgrew it as a teenager. There is nothing concerning on his physical exam, his abdomen is soft and non-tender in all quadrants.
Case Study #3: Lucy is a 13 year-old tween, who you have just met this past year. The family had moved from out of state and Lucy has had a hard time in adjusting to her new school, but she has made a few friends. She is a good student, and is active in drama club and music, not into sports. According to her family, she has always been sensitive to her environment; bright lights, loud noise and certain smells have always bothered her. She tends to get lightheaded when she stands up quickly, and is very bothered by her sweaty hands and feet. She is generally healthy, but does have some GERD symptoms and constipation. Her diet could be better, very selective and often complains of mild nausea in the morning. She has always been a terrible sleeper, since infancy. She started having her menses 6 months ago. She has started complaining of severe headaches for the past several months and they are here to see you about it.
Your visit: Lucy is here with her mother today. She reports that she has been getting really bad headaches for the past several months. They started out just once in a while and now she has headaches every week, sometimes more than 1, and usually after school. Pain is rated 6-9/10NRS on average and she gets these weird symptoms right before the headache comes (squiggly black lines in her vision). The headache is always on the L side- temple and behind her eye, and she feels nauseous, dizzy and really tired. Lights and noise bother her more than usual, and the smell of some foods makes it worse. She goes into her room, into the darkness and tries to go to sleep. She usually takes Tylenol or ibuprofen which helps a bit, but needs to go to sleep for a few hours to feel better. When she wakes up, she might still have a mild headache but feels lousy, back to normal the next day. She has not been sick lately, and has been feeling well, except for the headaches. The only other thing is that her periods are also really painful, lots of cramps, and this makes her miserable. In reviewing her family history, her mother does report members of her family who have migraine and thinks Lucy has migraine too. Lucy is not very physically active, sleeps poorly, and does not like to hydrate, especially at school (the bathroom is gross!). Her physical exam reveals her to be neurologically intact, though there is evidence of some autonomic symptoms, such as hyperhidrosis of the hands and feet, mild hand tremor, sensitivity in the distribution of the nuclear caudalis (trigeminal sensitivity).
Of course all 3 of these cases represent migraine or migraine variant. These are typical presentations that can be seen in the primary care office, and can be dealt with effectively there. In the next post, I will discuss possible interventions for each. In the meantime, think about what you would do for these children.
HeadFirst PNP 