Migraine and concussion case study

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.

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.

 

Migraine case studies, part 2

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.

Migraine case studies

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.

 

Chronic migraine, what to do?

So your patient has developed chronic migraine, which is defined as 3-4 migraine per week, 15 migraine days per month, and is predictably miserable. Developing chronic migraine does happen in pediatrics, but it happens much more often in older teens and adults.  You’ve done what you could to prevent it from happening: did a course of steroids, tried increasing their daily medications, worked on lifestyle issues and even sent them to the ED for a cocktail to break the cycle. The ED visit did help but the effect was not sustained, and your patient is back with frequent migraine again. Now what do you do?

I would suggest that this is the time to refer them to a headache specialist, in a clinical setting where there are experienced providers (MD, NP, psychology), skilled at dealing with chronic headache.   Headache programs are usually staffed by a neurologist, or possibly a pain specialist (and rarely by someone who is both) and also a pain psychologist.  Not every neurologist is interested in caring for kids with headaches but pediatric headache programs can be found all across the country. If there are no pediatric headache specialists in your area, there may be an adult provider willing to see an adolescent .  For children, it might be hard to find an alternate provider.  Pediatric headache programs are most often found within a university teaching hospital setting. Some are found within neurology or within a pain (anesthesia) program.

When patients are referred to our headache program, the initial evaluation is done by the pain/neurologist and a pain psychologist.  There are some up front data collection, including psychological measures (FDI, RCMAS-2, CDI-2, fear of pain index, pain catastrophizing scale), done online, prior to the visit. Their medical records are also reviewed. The families see the neurologist first for full history and physical, and then they seen by the pain psychologist- patient and parents, separately and together.  Then a plan is formulated and reviewed with the family by one of our PNPs.  The plan is usually a combination of medications, lifestyle measures, complementary therapies and often a recommendation for psychology for cognitive behavioral therapy (CBT) or physical therapy.

The overriding message to the patients and families is that this is condition that responds best to a multidisciplinary approach, each part of the plan is important. As you all know, each family is different and their expectations and culture vary widely.  Some families are more than happy to change medications, start supplements, even do PT for head and neck stretching and strengthening.  They may rather just focus on lifestyle measures, like working on hydration and sleep.  One of the hardest things to promote is psychology and CBT. Sometimes the family is well aware of mental health concerns, confirmed with the data from the psychological measures and meeting with our psychologist. They are open to the idea and welcome suggestions for where to seek counseling.

But it is often a hard sell to either the parent or patient or both. I encourage that even if there are no serious psychological challenges, having frequent migraine is a source of stress, and can get in the way of participating in life. Learning CBT can provide the teen with better ways to cope with the pain and underlying anxiety and stress. When meeting with particular reluctance/resistance on the part of the teenager, I emphasize that they are not going to ‘talk about your feelings’, but rather to learn concrete skills to use at times of increased pain and stress.  Sometimes the boys are more reluctant (but not always), and the suggestion to see a sports psychologist is better received. There are phone apps that can be used to augment or introduce the CBT exercises. In the end, there is no better way to engage in cognitive behavioral therapy than with a skilled therapist.

Treatments options for chronic migraine:  There are treatments available in a specialty clinic that are not easily obtained in the community. Providers are more familiar with different classes medications used for migraine.  We might be more comfortable in increasing dosing to a more therapeutic level or use medications in combination.  We might also introduce psychopharmacology to the treatment regimen, if indicated. Getting a good medication history is important to decide if the patient actually had an adequate clinical trial of a medication.  Sometimes patient will come in having tried 4-5 daily medications, over the course of 6 months.  Unless there are significant side effects, brief trials are not adequate to determine whether a medication would be helpful. Unfortunately, families and/or patients can have a ‘quick fix’ mentality and inability to tolerate any symptoms or pain, which leads to changing medications before really determining if they work.  Any medication used as a migraine preventive needs to be trialed for at least 2 months, starting low dose and increasing slowly as tolerated. This same approach should be applied to psychopharmacology as well.  This can be hard to communicate to families but necessary.

There are several inpatient options available for chronic or intractable migraine.  Patients can be admitted overnight for the typical migraine cocktail, using ketorolac IV q6h for 24hours, plus adjuncts and steroids. This can help to break a bad cycle, and generally well tolerated.  Also, IV Depakote can be added with mixed effects, followed by 3 days of oral depakote.

Another option is for the patient to be admitted for several days for IV DHE (6 doses, q8h).  This is less well tolerated, with side effects that need to be treated.  Nausea is significant and DHE is generally pretreated with metoclopramide and Benadryl, compazine, ondansetron or even lorazepam.  This can be effective in resetting the migraine pattern back to episodic. Not always pleasant but worth a try.

There are 2 outpatient injection procedures used to decrease the chronicity of migraine.  First there are occipital nerve and trigger point injections, done with local anesthesia (lidocaine and bupivacaine+/- steroids).  The occipital nerve can be inflamed. Trigger points (areas within muscles that are very irritable) will contribute to migraine, other headaches, and myofascial pain.  The area around the greater occipital nerve, as well as any trigger points in the upper cervical, trapezius muscles is infiltrated with local anesthetic.  Initially, patients feel ‘heavy-headed’ or numb, which passes by the next day or so.  The anesthetic medication blocks pain receptors within the nerves surrounding the muscle, thus reducing the pain signals sent to the brain.  Your patient may feel immediate relief of pain, and then (hopefully) a reduction in incidence of migraine.  Some patients have significant improvement with this procedure; some have no benefit at all.  It is generally well tolerated.

Botox© is the only treatment approved by the FDA for chronic migraine for patients over 18 years.  There are strict criteria for its use and generally insurance companies stick to the rules. We have been able to get approval for a few 16 year olds but this is rare. The criteria includes: 15 migraine days/month, migraines lasting up to 4 hours, failure of several preventive and rescue medications. It is not approved for episodic migraine. Another office procedure, the patient will have 155units of Botox© injected via a 30G needle in 31 specific locations on the face, cranium and neck/shoulders, every 3 months. As you can imagine, this is not the easiest thing for a teenager to go through, causing distress and tears. However, in our practice, we have found it to be fairly effective, with decrease in migraine frequency and intensity in many patients, especially after the 2nd procedure.  It is also generally well tolerated.  Most kids tell me that they hate getting the Botox©, but the results make it worth it.  They joke that they know when it’s time to come back when they move their eyebrows again. I was initially skeptical, wondering if it really worked.  But after performing the procedure many times now and seeing the results, almost all positive, I have become a believer.  There is nothing better than getting kids back to functioning.

Your role: So what happens after your patient is seeing a headache specialist? Does this mean you no longer have a role in managing your patient’s migraines? Of course not! As a headache specialist, I enjoy partnering with primary care providers in the overall care of these patients. The families may come from far away, and only come in to see us every 3-6 months. Their community provider is crucial in supporting the families during the difficult time of chronic migraine. We welcome contact, questions and updates.  These families need as much support as they can get, to keep OUR patient functioning, and avoid disability.

So that’s it for now about migraine. I plan to do a case study next to show migraine management in practice.

When migraine turns chronic

So when does episodic migraine transform into chronic migraine? Well, it’s a matter of frequency. The International Headache Society defines chronic migraine as more than 15 headache days per month over a three month period of which more than eight are migrainous, in the absence of medication over use (2-3+ times per week).

Often your patient will be managing their migraine adequately, has a good effective rescue plan, perhaps on a daily medication. Then something happens- a bad viral illness, a mild concussion, environmental stress or trauma, school stress, leading to impaired headache self care- and migraine gets out of control.  Intervening quickly in this destructive pattern, if possible, is best to avoid transforming into a chronic pattern.

So what do you do when it seems that headaches or migraine are worsening? There are several things that can be helpful. I will often start with doing a quick course of steroids- Medrol dose pack, to intervene and reduce inflammation, trying to reset the migraine control center. I might look at their daily medications and effectiveness and consider increasing the dose for a time. Or I might start a daily medication. At times, I might consider an ED visit or few nights hospitalization for DHE (or something else) to help reset.

Then I look at figuring out triggering the increase in migraine and intervene with that. Has there been a viral infection? Mild head trauma? Stressful family/school/friend situation? What has been done to intervene already? In the case of an infection, has the patient been taking care of themselves, resting, hydration, sleep, good hand hygiene, etc.  Have they checked in with their PCP for anything else going on?

For head trauma, it is important to know that for folks with headaches or migraine, they are much more likely to have concussion-like symptoms from a mild head trauma than other people, due to their baseline neurologic sensitivity. It may not have been a significant blow with loss of consciousness, but the migraineurs can have full blown concussion symptoms, such as severe constant headache, dizziness, nausea, fatigue, disrupted sleep, difficulty with concentration and screens and focus, and so on. It can be difficult at times to get the teens to really maintain cognitive rest, get off their screens, and allow their brains to heal. Pushing through generally just prolongs the recovery. The sooner this is recognized and steps are taken with regards to school accommodations, the better. Then time will help the healing process. I have had many calls and conversations from families about the difficulty managing concussion symptoms. Oftentimes, the teens are very diligent, striving and responsible students, and trying to get them to slow down and let their brains recover is such a challenge. These are families who are great at managing episodic migraine, but concussion issues are always more difficult than expected. Cooperation and understanding from school personnel can really help in these situations.

In the case of increased environmental stress, being open and honest about what is going on, acknowledging the role stress is playing in headache is the starting point for dealing with these issues. Every situation is different, and often we can trouble shoot and problem solve together to help improve the situation. Just talking about it with someone outside the situation can be therapeutic. If there is counseling in place, that’s a plus.  I always talk about stress management strategies during visits and have a number of suggestions, including meditation apps, breathing exercises, yoga, exercise, and counseling. There are times when anxiety is significantly contributing to the stressful environment, and an SSRI can be started to help.  I have a rule that if I am going to prescribe something for anxiety, they have to agree to get into counseling. It may take some work to get the counseling but quite beneficial. Having a good trusting relationship with the teen and family is the key to being able to have difficult conversations, which can lead to successful care and treatment.

Finally there is an emphasis on getting back to basics of headache healthy habits. I check in on hydration, sleep habits and hygiene, diet, and physical activity. If they are falling down in any of these areas, I encourage getting back to basics. Reviewing their habits can bring unhealthy patterns to light, which allows them to be worked on and corrected. They often do not even recognize they have gone off the track, due to their distress.

Families will call frequently, feeling out of control, in distress. In my opinion, the best thing to do is to get them into the office for evaluation as soon as you can. In fact, any patient going through difficulty should be seen more often in the office. I find that phone contact is useful, but when they are calling nearly daily, face-to-face is needed to get the train back on the tracks. The best way to make sure your instructions are being understood is to interact with them in person. This also communicates to the patient and family that you care about their well-being, want to help, and take them seriously. And there is definitely therapeutic benefit from the in-office personal assessment. Of course, they cannot always get to the office, but outcomes tend to be better when they can.

In my office, we try to not completely fill my schedule every day, in order to accommodate an urgent visit. The wonderful physician I work with is a neurologist, specializing in pain, and sees all the new patients, with some follow ups.  I see all follow up patients, so I can be a little more flexible and can make space. This can be helpful in throwing a lifeline to a family in distress, whether they choose to take it or not.

So basically, as soon as it is recognized that migraine has started to transform to chronic migraine, it is important to intervene quickly. This can often prevent true chronicity, which needs to be avoided at all costs.

In my next post, I will talk about chronic migraine, appropriate treatments and interventions for children and adolescents.

Daily medications for migraines, part 2

In this post, I am going to discuss the ins and outs of prescribing a daily medication for migraine prophylaxis. In the last post, I identified one migraine/week as a benchmark for considering a daily preventive medication. Here’s the run down on the basic daily meds that primary care providers could start for their patients with frequent migraine.

There are several groups on medications commonly used to prevent migraine.  They are antihistamines (cyproheptadine), tricyclic antidepressants (amitriptyline, nortriptyline), anticonvulsants (topiramate, zonisamide, gabapentin), beta blockers (propranolol) or calcium channel blockers (verapamil). Your choice is based on age, other comorbidities, side effects you want to avoid (or can help with other issues). As with all things headache, you start with low dosing and increase as needed (low and slow). For most of these medications, significant side effects include mental clouding, sedation, and at times, mood alteration (irritability).

Cyproheptadine (Periactin) is an antihistamine with anti-serotonergic and calcium channel blocker properties.  It is most effective as a migraine preventive before puberty. Expected side effects include sedation and weight gain/increased appetite, and is generally taken at bedtime.  For kids who have trouble with sleep, the sleepiness can help establish a better sleep pattern. If dietary intake is an issue, this can help. As is often the case with antihistamines, there can sometimes be some irritability or mood issues.  I always mention this, and if a child has had a paradoxical reaction to Benadryl, I don’t use it.  Starting dose is 2-4mg QHS, and it does come as a liquid, which does not taste too bad.

Tricyclic antidepressants: the most common TCAs for pediatric headache prevention are amitriptyline and nortriptyline. Amitriptyline is more effective but has more side effects than nortriptyline. The typical side effects are sedation and mental clouding. Since nortriptyline does come as a (bad tasting) liquid, it is used more often in the youngest kids. The usual starting dose for amitriptyline is 10mg QHS, with slow titration as needed. You should get an EKG to make sure there are no heart rhythm abnormalities first.  Again sleepiness from the medication can help with troubled sleeper. The main things to monitor are daytime sleepiness and mental clouding. It’s a fine dance to achieve medication effectiveness with minimal side effects.

Antiepileptic drugs, most commonly topiramate and gabapentin are also among the first line of migraine preventive medications.  From our knowledge of migraine pathophysiology, it seems that these medications can alter the migrating wave of regional cortical excitation followed by a prolonged period of neuronal depression that happens during a migraine attack. These medications do vary with their side effects, though both cause mental clouding.

Topiramate is one of our starter preventive medications, can cause paresthesias and significant appetite suppression, and generally not sedating. Dosing can be daily or BID, lowest dose is the 15mg sprinkle cap, no liquid form is available. If topiramate seems somewhat effective but there are too many side effects to continue, you could try zonisamide, next generation of topiramate, less effective but less side effects.

Gabapentin does cause sedation, may lead to weight gain as well. Dosing is at bedtime to start, though depending on toleration, it can be given up to TID. At most I will use  BID dosing (bigger dose at bedtime), as that midday dose is often missed. It comes in capsule form, smallest dosing is 100mg, though it does come as a liquid, helpful for younger children. I might choose gabapentin if there is an element of occipital neuralgia or neck pain.

Antihypertensive drugs: These medications dilate the cerebral blood vessels and interacts with serotonergic systems involved in migraine pathogenesis. They can be effective in migraine prevention, but it is also unclear how exactly these mechanisms work.

Propranolol (beta blocker, Inderal) is one of the most common medications used for migraine prevention. It is contraindicated for kids with asthma or RAD, and might not be a good choice for athletes as it blocks the effect of adrenaline, reduce blood pressure and slows the heart beat. Verapamil (calcium channel blocker), is helpful for those patients with significant dizziness or vertigo.  It should be avoided for any patients with significant cardiac abnormalities.  Dosing for both medications is generally BID, though after therapeutic dose has been established, they can be transitioned to an extended release product.  I advise being vigilant with hydration and having electrolyte-rich drinks and salty snacks available due to the likelihood of lightheadedness. Neither of these medications cause mental clouding.

A few tips:

  • A word on mental clouding- kids have no idea what you are talking about when you say mental clouding.  I describe it as ‘feeling dumb or not being able to think straight’ and they understand that.  Since learning is their job, it’s an important consideration; unfortunately, nearly all of our preventive medications have this as a side effect.
  • A specific consideration for TCAs: amitriptyline can be lethal taken in large doses. If there are any mental health concerns, the parents need to know this and take appropriate safety steps.  For my teens going off to college, if I have not told them this before, I make sure they know about the lethality of amitriptyline and advise keeping it locked up, under wraps, out of the hands of a depressed schoolmate. It’s scary but they need to know.
  •  It usually takes weeks to 1 month to notice any positive effects from these medications on migraine frequency and severity.  Families need to have patience, as the higher the dosing, the more likely the side effects.
  • A common situation: your patient thinks the medication is not helping them.  The teen may just stop the medication or forgets to take it for a few days. Sometimes these episodes show the patient that medications are actually helpful (or not). Can be a useful experience.
  • One helpful tip for the reluctant patient is to stress that taking a daily medication is not forever. Setting a time line (4-6 months), or deciding to wean off at the end of the school year, can help with the buy-in.

So those are the basic medications used for migraine (and other headache) prevention. Starting a daily medication is always a group decision between the provider, family and patient, and no matter how strongly you and/or the parents feel about medications, your patient may not want to do this.  I feel strongly that without full buy-in from the patient for taking a daily medication, there is no point to doing it. Without the patient’s agreement and cooperation, this is a set up for daily family arguments, inconsistency and noncompliance.

Plus, I think in the world of headache and migraine, kids/teens deserve to have a say in their treatment.  It is always worth a conversation with your patient about why they do not want to take a daily medication.  Questions can be answered, reassurance given, and the importance of daily compliance stressed.  If in the end they are not willing to commit, then that’s it. No matter what the parent wants, a daily medication demands daily compliance. Many of our older kids and teens are able to take agency for their own health, and in doing so, they can partner with you in improving their health.