So in the past few posts I have talked about the effect of a concussion can have on a patient with an existing headache diagnosis. Now let’s take a look at a classic headache clinic presentation as case study. I am using a composite of patients and situations, commonly seen in primary care.
Background: Joe is a 17+ year-old young man with episodic migraine with and without aura for the past few years. He is not on any preventive medications, and has been having migraine headaches at most once per month. While his migraine episodes are infrequent, they can often last a few days. Joe has an aura of neck pain 50% of the time. His pain score on average is 7/10NRS, pain is located all over his head, and accompanied by abdominal pain, photophobia greater than phonophobia, fatigue and nausea. He usually takes sumatriptan 50-100mg, with naproxen 500mg and ondansetron 4mg, which are effective. At times, he may need a Medrol dose pack, which is effective with prolonged migraine. Triggers for Joe tend to be seasonal changes, stress, barometric pressure changes, lack of sleep and dehydration. He did have a mild concussion in 2015 (#1), had a reasonable recovery time. You have followed Joe for the past 4 years. Joe does a good job with his healthy lifestyle; he sleeps well, stays active playing basketball, drinks well and has a healthy diet. He could do a better job with stress management, mainly using the “Netflix and chilling out” strategy. He is an excellent student, takes his academic achievement seriously. He is also a great kid, polite, respectful and funny.
Situation: In late December 2016, Joe suffered a mild concussion (#2) during basketball tryouts. He was seen by his PCP soon after the incident. You had contact with the family by phone several times, and saw him in the office in February 2018. He did not lose consciousness, did missed 5 days of school, at home on cognitive rest. He had significant headache for 10 days, as well as dizziness, fogginess, irritable, difficulty with screens and school work. He used a Medrol dose pack and took naproxen BID for 5 days right after the incident. His symptoms slowly regressed and he feels like it took about 1 month for the majority of symptoms to subside. He still had slower reaction time with basketball and took longer to process information. He had some accommodations at school, and took appropriate breaks and use extra time if needed.
It took another month (2 months total) before Joe felt like he was back to normal and fully functional. His migraine headaches did not get significantly worse during this incident, he did not need to start a daily medication. Joe had a routine follow up appointment during the summer 2017 and continued to do well. He was having more stress heading into his senior year around the college application process.
Fast forward to concussion #3: In early October 2017, Joe was hit in the head with a hard-thrown ball in PE class. He reports no LOC but was immediately unsteady and had headache. Shortly after the blow, he became nauseous and dizzy, no confusion. He was seen in the ED immediately after the incident, had a CT scan which was negative. You have talked to the family on the phone since the incident and decided not to use a Medrol dose pack, as it was not well tolerated the last time (nausea, sleep disruption).
You see him in the office 3 weeks later and he has significantly decreased nausea and dizziness but constant headache, rated 5-6/10NRS, worse with exposures (light, noise, smell, general commotion) and concentration. Along with headache, he has phonophobia, photophobia and osmophobia, difficulty with reading and comprehension, using some computer screens, fatigue, sleep disruption and moody/cranky. Initially he was taking naproxen and Tylenol around the clock for the first week, and then stopped naproxen which improved his nausea. He has since been using Tylenol or Excedrin migraine daily, caffeine being very helpful in the AM. He did try hydroxyzine to help with sleep but had a paradoxical reaction to it (felt wired).
He has some accommodations at school, has access to a supportive learning classroom during study and has been excused from gym. He has had a few absences and early dismissals. He is having lots of stress and anxiety about missing classes and tests, which increases headache. He is currently not doing any physical activity. Joe is struggling with his recovery and feels he is not getting better. You do remind him that it took a full 2 months after his last head hit to be back to baseline, just to reset expectations. This is a predictably stressful time, with the college application process going on.
Decision point: He was advised to stop daily analgesia, can drink a caffeinated drink in the Am and around lunch, if it is helpful. He may use Tylenol on a limited basis, no more than 3 days/week. You talk again about how even a mild head trauma can cause concussion-like symptoms and recovery should be dealt with as a post-concussion recovery. You talk about concussion accommodations, give written information, and they will discuss together about what he might need going forward. He will continue to take frequent breaks. You encourage starting some physical activity using the home exercise bike, in a graded fashion. You introduce Joe to the Insight Timer meditation app to use when trying to de-stress, sleep and decrease pain. He was encouraged to continue with good hydration and sleep hygiene, and to do what was needed to recover, emphasizing that pushing through no matter what would only prolong the recovery. You ask the family to check in with you in a few weeks or sooner with an update.
Update: You have had several phone calls, once every other week, for support and guidance over the past 6 weeks. Joe is very slowly getting better. His headache has diminished, no longer daily but 2-3 times/week. He is able to tolerate being in school now for a full day, only rarely taking breaks during the day. Sleep is back to normal and Joe is back to his usual mood, no longer irritable. Migraines are more often than baseline still, 2-3 per month. You continue to encourage slow and steady return to full functioning, glad to see he is on a positive trajectory.
Follow up appointment visit: You see him in the office in February 2018, 5 months after his 3rd concussion. He is fully recovered now. Migraine frequency and severity is also back to normal. You talk with Joe and his family about trying to avoid further concussion, but acknowledging that sometimes things happen. At least doing his best to avoid risky situations would be useful. They wonder if his concussions are putting his brain at risk in the future. You don’t know for sure, but know there is considerable research ongoing which should shed more light on the subject.
So this is a fairly typical presentation of a teenaged migraineurs who has had several mild head traumas, leading to progressively more symptomatic and prolonged recovery. The closer in time the traumas occur, the more likely the recovery will take longer than expected. The key to recovery is recognizing the problem, cognitive rest for a short period of time and then progressive return to functioning. Joe’s school (and many others) had a supportive option available for these situations which was quite helpful. And the more information that is disseminated about the difficulty of patients with a headache diagnosis have in recovering from concussion, the better and less stressful the outcome.
HeadFirst PNP 