Here are the case studies with 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.
Your intervention: You propose that these headaches are most likely migraine, based on the symptoms, history and family history. As her migraines are infrequent, the focus of your intervention is going to be on lifestyle factors and rescue methods and medications.
You talk with the family about the importance of getting a good night’s sleep (10 hours for kids her age), lots of healthy exercise and no meal skipping. Sally weighs 24kg, so her daily hydration goal is 20-25 ounces (at least 1oz/kg/day or half their body weight in pounds), more in the hot weather and with exercise. You give them information about the migraine elimination diet and any office materials you have about migraine headache. Sadly, she may have to eliminate or at least limit the amount of chocolate she eats, and perhaps make other adjustments, such as keeping to a regular sleep schedule even on weekends and limit sleepovers.
You advise using ibuprofen 200mg (1 adult, 2 chewable tabs or liquid) at the start of the migraine, hydrating with water or electrolyte-rich drink (Gatorade, Smart water, etc.) and then taking a nap for rescue. She can also try using an ice pack on her head, keeping her room dark, quiet and cool. Encourage them to keep a headache diary so that they can give you good data at their next appointment in several months as follow up. Offer reassurance and support that you will work as a team to manage her migraine headaches.
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.
Your intervention: You approach this from a GI perspective, first exploring sources of GI pain, checking an XRAY for constipation and other abnormalities, such as intussusception, checking a stool sample, checking labs for celiac, etc. When it all comes back negative, you propose that these symptoms are consistent with a migraine variant, called abdominal migraine, something particular to children. This diagnosis is supported by his overall wellness, the episodic frequency and his symptoms while having pain, and the family history (uncle with similar presentation). As this migraine is rather frequent, you consider a daily medication, as well as lifestyle factors and rescue methods and medications.
As with the previous case study, lifestyle is key in preventing abdominal migraine; sleep, diet, hydration and exercise can help limit the migraine episodes. The family has already noticed some possible triggers, and is advised to avoid Chinese food (or at least MSG) and to start reading processed food labels for it. Information about the migraine elimination diet and office materials about migraine is helpful. There may need to be lifestyle adjustments, enforcing a regular sleep schedule, making sure Charlie brings water to school every day to meet his daily hydration goal (34kg=30-40oz), extra with sports.
Lifestyle measures may be all he needs to decrease the abdominal migraine frequency. But if not, an appropriate daily medication to try would be cyproheptadine 2-4mg at bedtime. This works quite well in pre-pubertal children, though you have to be sure to mention the side effects of increased appetite, sleepiness and at times, irritability. (If he is grumpy with diphenhydramine, I might not choose it, perhaps choosing amitriptyline instead.)
For rescue, if Charlie is very nauseous, he can take ondansetron 4mg dissolving tabs ODT first. Then he can use ibuprofen 200-300mg (1 1/2 adult or 3 chewable tabs), OTC Aleve 220mg or prescription naproxen 250mg at the start of the migraine. He should hydrate with water or electrolyte-rich drink and then taking a nap for rescue, resting in a dark, quiet and cool room. The family can keep a migraine diary so that they can give you good data at their next appointment in several months as follow up. One thing about abdominal migraine is that they are changeable. As time goes on, he may very well transition from just abdominal pain to a combination of abdominal and head pain. As children proceed through puberty into later teenage years, abdominal migraine either just goes away completely, or transforms into migraine headache. As he is a male, his migraine may just disappear at the end of puberty, similar to his uncle.
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) and GI issues.
Your interventions: You propose that these headaches are most likely migraine with aura, based on the symptoms, history and family history. She also is neurologically sensitive, with some autonomic nervous system dysfunction. Her case is bit more complex, more moving parts and will require a multidisciplinary approach, including daily and rescue medications, and lifestyle improvement.
Early adolescence is a time of great upheaval, physically, hormonally, socially and emotionally. It is also a time when migraine often appears. Being a sensitive individual since infancy, Lucy is more prone to the ups and downs of this period, and may not have the coping skills she needs to navigate to good health.
Focusing on lifestyle, there are many areas for improvement. But bringing them all up at once is usually overwhelming and unproductive. A step-wise approach will be more helpful and gain her cooperation. Her sleep is not great, she is not active and is not hydrating enough (55kg=50-60 oz/day). Considering her other symptoms, I would probably first put the most focus on hydration, which would certainly help with her dizziness and nausea. At least until her headaches are better, I would encourage having an electrolyte-rich drink every day, preferably in the AM before school. Lucy should also have a 20-24oz water bottle with her at school every day and bring it home empty. The parents can check out the issue with the school bathrooms, try to identify the cleanest of them all, perhaps near guidance or the nurse’s office.
The next thing to focus on would be exercise with a goal of 30 minutes 3 times/week, doing whatever she enjoys, such as dancing, swimming or bike riding. Sleep is a longstanding issue, and guidelines for sleep hygiene can be shared and slowly worked on, such as no phone charging in her room overnight for a start. I would also make sure that there is no meal skipping, especially at school. If there are concerns about anxiety, that should be explored and if appropriate, counseling for coping with pain and anxiety can be helpful (CBT). Learning to turn on the relaxation response (CBT, meditation, yoga) can also help calm down her autonomic nervous system and reduce a lot of her environmental sensitivities.
There are several daily medications which would be appropriate for Lucy. I might choose amitriptyline or gabapentin in particular, as they do cause sleepiness and might help with her poor sleep. If she is a poor eater or there is worry about restrictive eating, I would probably not choose topiramate. Almost all headache medications cause mental clouding so the lowest effective dose is best. Propranolol could be used too, as she is not asthmatic nor a performance athlete, though hydration is really important with this medication. It is important to stress that it takes at least 1 month for any difference to be noticed.
For rescue, since she does have aura, Lucy could try a triptan at the earliest evidence of migraine aura, such as rizatriptan. After a dose and rest, if her migraine is aborted, that’s all she needs. Often a combination of a triptan and analgesia is needed for most effective treatment. The simplest thing is often a combination of a triptan and naproxen, using antiemetic as needed. You can strongly urge no more than 3 days of analgesia per week. Again keeping a diary, perhaps using the Migraine Buddy app, to gather good data will be helpful.
She can use the naproxen for her menstrual cramps too. As she gets older, she may discover that she always gets a migraine around her period. She might want to try an oral contraceptive to help with her dysmenorrhea. Since she has aura, this needs to be done with caution. We recommend using progestin-only preparations with aura, at least to start, perhaps with the guidance of a GYN.
It might take a few visits to help Lucy feel better, but I would encourage focusing on all 3 areas from the start to help her. Her daily medication may start to decrease her migraine frequency, a better rescue plan makes her feel more positive and in control, more hydration and a little better sleep will help too. Then you can move on to adjusting her medications as needed, promoting more positive lifestyle changes, helping her to improve her coping skills and resilience. Frequent office visits can really help families make the necessary changes, with your positive encouragement and obvious caring practices. There is nothing more satisfying than guiding a teen and her family toward having self-agency and competence in dealing with a chronic health issue.
So you can see that these are fairly typical patients seen in primary care. I didn’t go into it, but supplements, and complementary interventions are often a part of treatment, as mentioned in pervious posts. I hope that these case studies are helpful in guiding your clinical decision making. I will include some patient migraine information in the reference materials. I think I will do another case study in the next post, this time focusing on someone with increased medical complexity, who needs a team approach.
HeadFirst PNP 