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.

The Impact of concussion on teens with headache

There is much evidence and information in the literature about the general effect of concussion on kids and teens.  Most pediatric practices and schools use specific protocols for concussion recovery and these plans generally work well. Unfortunately, for patients with headache, the story of recovery can be quite different.  In this post, I would like to discuss the impact of concussion/mild head trauma on patients with a headache history.

A concussion happens when there is an impact injury to the skull that mildly damages the brain tissue, causing bruising and swelling. Immediate symptoms of a concussion can include a loss of consciousness, confusion, amnesia, nausea, vomiting, headache or dizziness. Some signs of a concussion may not appear for several hours after the injury and may persist for several days or weeks.

Post-concussion symptoms are caused by both physiologic and psychological factors from the effect of brain trauma. Physically, symptoms can be caused by structural damage to the brain or disruption of the neurological messaging system, triggered by impact. Psychological factors can be involved, since many of the symptoms, including headache, dizziness and sleep disruption, can also be attributed to depression, anxiety or PTSD.

Healthy teens generally recover from their concussions within a reasonable amount of time, especially if they follow the usual post-concussion guidelines, instituting cognitive and physical rest for a period of time. Depending on the severity of the injury, recovery can be complete within 3-4 weeks, with a gradual return to function.

Unfortunately, teens with a headache history (migraine, tension-type, new daily persistent headache) have a much more difficult time with their recovery. In fact, migraine is a risk factor for prolonged concussion recovery. Even when the head blow is quite mild, kids with headache tend to be much more symptomatic, diagnosed with a concussion. Whether it is a true ‘concussion’ or not, these patients have significant symptoms consistent with concussion. And they are much more at risk for developing post-concussion syndrome.

Post-concussion syndrome (PCS) is a condition in which the symptoms of a concussion persist for weeks, months or years. Symptoms of PCS include:

  • Headache: recurrent or constant mild to severe headache pain
  • Sleep: disruption, insomnia, daytime fatigue.
  • Mood: anxiety, irritability, depression, confusion
  • Sensory Alterations: blurred or double vision, slurred speech, altered sense of smell or taste, tinnitus or hearing loss, photophobia and phonophobia
  • GI complaints: nausea, vomiting, decreased appetite
  • Balance issues: unsteadiness, lightheadedness, dizziness or vertigo
  • Cognition: forgetfulness, misplacing common items, difficulty concentration and focus, comprehension and reading

After concussion, migraineurs tend to have more frequent and severe migraine episodes. The migraines become more difficult to treat with their usual rescue medications. For patients with TTH, there can also be more severe symptoms, often related to muscle spasms and tightness, especially if there was a whiplash injury. For NDPH patients, their overall baseline headache pain is increased with more frequent headache spikes and other symptoms.

Overall, having a mild head trauma can cause considerable symptoms and even the development of disability in your usually well-functioning teenager with headaches. For primary care providers, awareness of the likelihood of prolonged recovery for these patients is key.  Realistic expectations can be set with the patient and family. PCPs can assist in obtaining accommodations for school and academic demands, as well as supportive therapies to foster recovery. Emotional support is very important, as the results of these types of unexpected injuries can really test the resilience of the any family unit.

It’s important to remember that these types of injuries are not just sports-related.  One of the most prolonged and symptomatic PCS patient in my practice was a teenage girl with migraine who slipped and hit her head on the side of a bathroom sink. She was out of school for months and suffered greatly from this injury, requiring a lot of support and intervention to get back to functioning.  And then she fell and hit her head on the ice the following winter! She made a full recovery but….. oh my goodness.

In my next post, I will talk about care and treatment of the patient with headache and concussion.

 

 

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.