Migraine case study, part 3

In this case study we’ll look at a fairly straightforward patient, with some twists and turns and decision points along the way.

Case Study: Patty is currently an 18 year-old teenage girl with a history of migraine headaches since age 9. You have been seeing her for years, and this is her story.  At the time of diagnosis, her migraines were infrequent (monthly at most), easy managed with a dose of ibuprofen and a nap. She was on no daily medications, and did a good job with her healthy headache hygiene. She is otherwise healthy except for exercise-induced asthma, just uses an inhaler as needed. She lives at home with her parents, 2 younger brothers, and several pets.  There is a strong family history of migraine

Around ages 11-12, things started to change, puberty was arriving. During this time her migraines were a bit more frequent, still manageable. Once her menses started, things really took off. Migraine frequency changed from monthly to weekly, and around her menses, they were more intense. She started to notice some aura-like symptoms, such as a black spot in her line of vision 30 minutes before the migraine started (50% of the time). She would also get more moody than usual 1 day before a migraine. She was also more symptomatic, having pain on average at 6-7/10NRS, accompanied by nausea with vomiting and lightheadedness, photophobia and phonophobia, fatigue, and that black visual spot. Ibuprofen was no longer effective and she often threw it up. Sleep was the only thing that helped, and the migraine lasted for several hours.  For lifestyle, she does sleep well at night, and eats a selective diet but no meal skipping.  Hydration is fair; she weighs 45kg and is drinking only 20oz/day and not drinking at school.  She is physically active with soccer and softball.

Decision point: Patty has reached puberty and her migraine headaches have become more frequent and symptomatic.  You decide that it is time to change her rescue plan, and consider a daily medication or at least a supplement.  The family would prefer not to start a medication, so you give them the option of starting daily magnesium 400mg daily as supplement. You also ask that she do a better job with hydration, at least 50 oz/day, and to bring water to school (and drink it).  You also reinforce her already healthy habits.  For rescue, you introduce a triptan, rizatriptan 5mg ODT (dissolving tab) to be taken when she notices her black spot before the migraine hits.  You also provide ondansetron 4mg ODT for her nausea, to be followed by naproxen 375mg.  She may take just the ondansetron and naproxen if no aura or the migraine is already started.  Since her migraines are just weekly, it is unlikely she will overuse medication but you do remind them that migraine analgesia should not be used more then 2-3 days/week. You ask them to return for a follow up appointment in 2 months to see how she is doing.

Follow up appointment visit: Patty is doing much better with her hydration, taking magnesium every day, and her rescue plan is working pretty well.  If she can take the rizatriptan quickly, many times she is able to abort her migraines.  And best of all, her migraines have reduced to 1-2 times/month; usually one of these times is around her menses.

Fast forward 2 years: Patty is here for her yearly check-up, age 14, in the summer before she starts high school. She is doing fairly well though her migraines are more frequent these days, back to once/week.  Her rescue medications are working well.  She has been using the Migraine Buddy app and tracking her headaches, has discovered that stress, caffeine and her menses are the biggest triggers.  She still takes magnesium but as not regularly, has backtracked a bit on hydration and has stopped playing sports.  She is also not sleeping well due to a busy mind, and her diet is slightly more adventurous, no meal skipping. She is particularly worried today about her migraines and starting high school, getting stressed out about it.  The family is thinking it might be a good idea to start a daily medication for migraine prevention.  Her health continues good, no recent illnesses or asthma flares.  Her weight is healthy, at 55kg.

Decision point: You agree with the family about trying a daily medication.  You consider your choices: cyproheptadine is not a good choice as she is beyond puberty and it will most likely cause too much weight gain; amitriptyline might be a good choice, might help with the anxiety  and sleep;  topiramate could also be chosen; Propranolol is not appropriate due to her asthma.  You choose amitriptyline 10mg at bedtime, may increase to 20mg after 1 month, and you check an EKG (normal).  You advise about side effects- sleepiness, mental clouding. She can continue magnesium if desired or try riboflavin B2 instead.  Lifestyle needs to be addressed and again you talk about hydration (60oz/day), sleep hygiene (put away that phone before bed), and getting more physical activity, since she is not doing sports now.  You also explore with the family ways to deal with stress, such as using a meditation app or exercise, seeing a counselor for CBT.  Patty is not really interested in counseling but she might try the Insight Timer app that you showed her how to use today. You ask them to return for a follow up appointment in 3 months to see how she is doing.

Follow up appointment visit: Patty is tolerating the amitriptyline at 20mg, no side effects and sleeping better.  She is having fewer migraine headaches back to twice/month. She did start hydrating better and now that school has restarted, she is in the habit of bringing a water bottle to school, empty when she gets home.  She is still not very active- none of her friends are active and she just wants to hang out with them.  The family does enforce better sleep hygiene with a set bedtime and phone out of her room at night. She is not in counseling and tried to do relaxation exercises but ‘found it a little to woo-woo’ for her liking.  Stress has not really been addressed, though the family is more aware of it now.  They are satisfied with her progress.

Fast forward, age 15, urgent care visit:  It’s winter and there’s a nasty GI virus going through the school, and Patty has gotten it. Patty has had a hard time, has been unable to tolerate fluids, vomiting and having diarrhea for the past 2 days.  And she just got her menses.  A perfect storm.  You see her in urgent care and she’s pale and miserable, and has a migraine on top of it all. She’s had a severe 9/10NRS headache for the past 12 hours, and is unable to take her rescue medications, take her daily amitriptyline or hydrate.

Decision point:  This is clearly not going to get better without intervention.  Fortunately, in your facility’s urgent care, patients can receive IV fluids and medications; otherwise you would need to send her to the local ED. An IV is started and she is given 500cc of saline to rehydrate to start.  Then, she receives a dose of IV ondansetron 4mg, and ketorolac 30mg, and perhaps Compazine 5mg.  Patty falls asleep and awakens in an hour feeling better, though still with a milder headache. You repeat the IV fluids and she is improved.  The family is comfortable taking her home.   You encourage them to continue hydration, electrolyte-rich fluids and antiemetics, and rest. In 1-2 days, all is well.

Fast forward, age 18, routine visit in December: Patty is doing well, in her senior year of high school, has gotten into her #1 choice for college. Her general health has been good, and apart from that 1 episode requiring urgent care, her migraine headaches have been manageable.  She remains on amitriptyline 25 mg nightly, and is having 2 migraines per month.  She does have a healthy lifestyle, doing well with hydration and reports that she has ‘finally learned that I have to drink a lot to prevent migraine’.  She enjoys being outdoors and hiking and kayaking now, and enjoys feeling physically strong and able.  She has a passion for the environment and wants to make a difference in the world through her environmental work in the future. She wants to talk about her menstrual migraines and also about birth control. She has always had bad periods with lots of cramps, and gets a very bad migraine on day #1.  She did some research (Dr. Google) and found out that some people with menstrual migraines and bad periods do better if they are on birth control.  Plus she has a new boyfriend, and has some other concerns as well. She continues to experience her aura of black spots, almost every migraine, and sometimes loses vision in one eye.  Rizatriptan is not as effective as it used to be, especially around her menses.

Decision point: This is a tricky situation, as women with migraine with aura have to be very careful with birth control choices. The general rule is to avoid estrogen-containing OCP, to avoid increased risk of stroke, at least as a start (see article in resources). Patty is correct that being on an OCP can help with dysmenorrhea and menstrual migraine.  You might suggest a progestin-only product, or refer her to a gynecologist.  Progestin-only OCP tend to be a little challenging as they often need to be taken at a consistent time, but there are other options as well such as depo-provera or progestin-only implant. One thing you can do today is switch her from rizatriptan to frovatriptan, the triptan that was specially developed for use with menstrual migraine.  Patty states she would be happy if her menstrual migraines were better; she might even want to stop taking amitriptyline. You and Patty decide that she will see a gynecologist about her birth control.  Once she is on a stable regimen, she can decide about stopping amitriptyline.  You ask her to consider waiting until summer break to do this, as she always has less migraine then and will have less stress.  She agrees and will come for a follow up during the summer.

So there you have it, an example of a typical migraineur from childhood through adolescence. The issues that present themselves here can all be well managed in the primary care setting. Most migraineurs end up in the ED at times, especially during times of illness and it may be unavoidable. These ED visits should not be considered failures. Rather they can be opportunities to fine tune rescue plans or reinforce a healthy lifestyle.   I always tell my patients that they will always be a migraineur, but their migraine headaches will change over their lifespan, for better and worse. Patients with migraine need education and empowerment to keep up with their self-care, and a caring provider to assist them.