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.

Concussion and the headache patient

In my last post I introduced the concept of concussion and the teenager with headaches. I would like to continue this topic by discussing what is helpful for these kids to help avoid disability and too much missed school.

The first step we recommend is for them to see their PCP or even the ED for a basic concussion exam. CT imaging can be useful with a history of more severe trauma, loss of consciousness or amnesia, or general concerns. The mild concussion diagnosis is then made and the usual recommendations of cognitive rest, physical rest, hydration and analgesia can be given.

For the teen with headaches, recent research using fMRI has shown that there is an element of neurogenic inflammation caused by head trauma. Often when the patients call us after concussion has occurred, we have them use a Medrol dose pack (dexamethasone taper), as way to reduce this inflammation. It can be quite helpful, though we really should try to do some research to quantify the results.   It is something to consider for those patients with baseline headache disorders who are very symptomatic.

So time goes by, the usual concussion recovery measures are done, and usually the teens will be feeling much better within 2 weeks. But for my patients with baseline headache disorders, that is not usually how it goes. So often, when one of my patients has a significant (or even not very significant) head bump, the families can go into panic mode. This is because the teen will often have more and prolonged symptoms than would be expected.

The initial symptoms will subside over time, leaving constant headache, and a variety of other complaints consistent with post-concussion syndrome. Besides headache, these symptoms include sleep disruption, moodiness, vision changes, hearing changes, persistent nausea, dizziness, vertigo, and cognitive difficulties, including inability to attend school and learn.  Since every teen and their responses are different, you need to address the issues at hand.  The symptoms that tend to become prolonged are those related to school functioning- trouble with reading, concentration and focus, and trouble related to the school environment –lights, noise, general overstimulation.

The first thing to address is the headache, and to make sure that they are not overusing analgesia. It is OK to use NSAIDS or Tylenol daily for up to 1 week, but much longer than that puts them at risk for developing medication overuse headaches.  So figuring out what they can do to feel better pain-wise is important.  We often talk about strategic use of medications, such as using naproxen during finals or before standardized testing is a smart way to medicate. They need to ensure excellent hydration and could try a little caffeine to help the pain.

For kids with sleep troubles and/or persistent nausea, I have found that a small dose of hydroxyzine (10-25mg) at bedtime can make a big improvement. Melatonin can be helpful for sleep (no more than 5mg), as well as the usual sleep hygiene recommendations (see an earlier post about lifestyle, All about the migraine part 2-3).

School!

There are many challenges for patients with post-concussion syndrome in returning to school. The school environment, with bright fluorescent lights, loud noise, and general commotion and overstimulation (think auditorium assemblies and basketball games in the gym), make school difficult to tolerate. This is true for teens with baseline headache disorders but worse after concussion.

Then there is the challenge of trying to think, focus and learn, especially frustrating for our teens who are natural ‘strivers’; those teens who are place high demands on their achievement. And it is very hard for these students to accept that they need accommodations and that they need to lower the bar of expectations for themselves, at least during recovery. Parents can also have difficulty with this, but they tend to have the maturity to understand what is needed, and can see the big picture. These kids worry me, as they are the ones at risk for becoming disabled, losing hope of ever feeling better, concerned about what the impact of the concussion will have on their future.  They can be unable to come to terms with the need for accommodations and slowing down, start to give up, and begin the slow decline towards disability.

So how can you help?

  • Support and frequent check-ins with the family can be very helpful to keeping them on track.
  • Work with the school on an appropriate re-entry plan, starting with partial days and frequent breaks during the day for cognitive rest. Some schools have special programs to help facilitate this, and can be really helpful. Asking for flexibility with the plan can make it more successful.
  • Enlist your patient to identify the problem areas of his/her day. Is it lunch in the loud cafeteria? Bright lights in English class, flickering lights in the science lab? Loud and hot environment in the gym/PE?   And after identifying the problems spots, work with the student to advocate for what can help them, such as preferential seating, excused from PE class, shutting off the lights, replacing a flickering light bulb, etc. Being able to make these changes can be very empowering and help them stay functional.
  • Cognitive rest is important and there needs to be emphasis on a gradual return to cognitive functioning and demands. They need reinforcement that overtaxing their brain will not help but only hurt them. There are specific accommodations that are helpful and I will attach a link here. Concussion Accommodations
  • For some teens, concentration and focus can be helped by a small dose of stimulant (methylphenidate or amphetamine), being mindful of other issues such as appetite and sleep.
  • Referral to Physical therapy for head and neck stretching. Referral for cognitive rehabilitative therapy (found with occupational or speech language therapy) can help with organization and functional skills post-concussion.  If you have a dedicated concussion center in your area, they will have these resources.
  • Return to physical activity is a slow process and using activity pacing is very useful. It is a difficult subject to explain but there is a series of You Tube videos done by a teenager with chronic pain that helps teens to figure out the concept. She discusses how to assess what is their current activity tolerance, how to set goals and reach them in a sensible measured way.  I put a link to these videos in the resources. YouTube videos on activity pacing
  • Finally, mood issues, irritability, anxiety and depression are a part of post-concussion syndrome. As the headache improves, this can improve also.  But as the duration of the symptoms continues, it is not uncommon for these kids to really get down and feel hopeless, or get very anxious about ever catching up in school and life. The most important thing is to be vigilant and refer to appropriate psychological clinicians as soon as you notice that the teen is having a difficult time. Explaining that feeling down and anxious can be a part of the post-concussion recovery and getting help them keep on the recovery track.

Awareness about the consequences of concussion is becoming much more mainstream. Less familiar is the effect of concussion is for those kids who already have baseline headache disorders. We owe it to our patients to be aware of the impact and support our families through this tough situation.

The challenge of taking care of patients with NDPH

I have recently reviewed the basics of New Daily Persistent Headache (NDPH) so providers in the community can have a better understanding of this primary headache.  It is often misdiagnosed, mainly due to unfamiliarity.  And now that you have a better understanding, you will be able to recognize it more readily.  One of the most frustrating things for the families is the lack of a firm diagnosis.  Many medications are tried and failed, some appropriate and some inappropriate.  They often express relief after a headache program evaluation, when the providers can explain what is really going on with their child.  The diagnosis is not good news, but uncertainty is often worse.

So what exactly can you do to help a patient with NDPH? Since I know that few medications are useful, I do not routinely recommend one.  I take my cues from the parents and patient, and sometimes they have different opinions.  Oftentimes, the parents are eager to try another med, anything to get this better.  But the teens I deal with really are not interested in doing another medication that ‘will not help me and just make me feel bad’. I generally agree with them.  They are usually interested in participating in research, anything to better understand the NDPH.

In the past 1-2 years, I have been recommending that they try the short-duration lidocaine infusion. The way I look at it, it’s a short intervention that is either going to help or not. But it will not make them worse, which makes it a big plus. And if it is helpful in reducing their symptoms other than headache, that has the potential for improving function and avoiding disability.

Apart from these kinds of initiatives, I just focus on the basics.  That means healthy headache hygiene, which includes adequate hydration, good anti-inflammatory diet, moderate but frequent exercise, and a good night’s sleep.  I reviewed these areas in previous posts (All about the migraine parts 2 & 3). This is even more important for the NDPH patient and most of them are challenged in one or more areas.  They are frequently my patients who don’t drink enough, eat a beige diet, and are persistently nauseous, don’t exercise at all, and have a hard time with sleep. It can be overwhelming to have to tackle many lifestyle issues, so we focus on one at a time, baby steps to improvement.

I like to see them in follow up every 3-4 months to keep them on track. Frequent reminders about any positive progress are also helpful.  When they are discouraged, I refer back to my notes from previous visits, citing an improvement in pain scores or general functioning that I documented 1 year before.  When you are in the weeds with this kind of chronic pain problem, you tend to not notice when things get better incrementally. It can give them encouragement to continue on the path to wellness.

A huge aspect of dealing with teens with NDPH is learning how to cope and manage their chronic pain and stress. I start with recommending counseling with CBT to help them learn pain coping skills. They can be resistant but I can be persistent.   (See previous post: stress and migraine).  There is usually an anxiety overlay in these patients- whether it was there before the headache or developed as a result of having chronic headache.  We can consider starting an SSRI as a way to manage anxiety and also to help with the headache.  I will explain the nervous system pathways for pain and anxiety are right next to each other, and that treating anxiety could very well help the headache.  This is almost always a helpful approach.  It doesn’t ‘cure’ the headache, but promote better coping ability which leads to better functioning, which can lead to NDPH improvement.

I have also tried occipital nerve and trigger point injections in those patients whose headache seems more focal or located in the occipital area. This has the possibility of improving the headache.  I ask that they come for 2 procedures before deciding it does not help. I would say it helps reduce the pain level in about 50% of my patients with NDPH (my guestimate). This is another intervention that could help, and generally does not make the headache worse in the long run.

Understanding and treating NDPH is a work in progress. Redirecting from ineffective and often invasive measures, following patients closely with an open mind and constant support, and emphasizing non-pharmacologic approaches  remain the standard of care until, hopefully, new research brings new insight.

Tension-type headache treatments

So you have diagnosed your teenaged patient with tension-type headaches, what are the next steps to prevent and treat them? The same questions apply to TTH as to migraine: Does this patient need a preventive or daily medication? What is the rescue plan? And even more importantly, what about the lifestyle factors that can trigger TTH?

Again, deciding on a preventive or daily medication depends on how much impact the TTHs are having on your teen patient’s life. Anything more than once per week deserves this conversation. And your choices for medication can be different than for migraine. When you think about the main causes for TTH, you think about muscular tension which can lead to muscle spasm and occipital neuralgia, and stress and anxiety.

For muscle tightness and/or spasm:  Oftentimes patient with TTH will awaken with a stiff neck and back or headache. Muscle relaxants given at bedtime can reduce neck tightness overnight, leading to less tension overall.  The most typical muscle relaxant we use is tizanidine (Zanaflex), an alpha2-adrenergic agonist, used for muscle spasticity. Usual dosage is 2-4 mg at bedtime. Main side effects are drowsiness, dry mouth, and weakness. It is used with caution for patient with impaired renal function and not advised for patients with impaired hepatic function.  If your patient has difficulty with sleep, tizanidine can also help with this. Cyclobenzaprine (Flexiril) is also a musculoskeletal relaxant, with a similar side effect profile and precautions. This medication is not recommended to be used for more than 2-3 weeks, and we do not generally use it.  Another option is diazepam (Valium), a benzodiazepine, but we almost never use it due to the risk of dependence and CNS depression. It is not a good choice.

What else can be done besides medications for tight muscles in the neck and upper back? The many different options of body work, such as massage, cranial sacral massage, chiropractic, yoga and Physical Therapy are very useful. I especially like PT, as there is a component and need for self-care required.  Sending your patient for PT for head and neck stretching and strengthening is a very useful therapeutic option.  PT is usually easy to find locally, though does require co-pay every time you go.  The patient needs to do their home exercise program as well for it to be effective.

A few years ago I recognized that for some families, doing PT was difficult- either because of the co-pay or the time commitment/hours of operation of the PT center. It just wasn’t happening and it needed to. With my yoga teacher, I developed a home head and neck stretching program to supplement or replace PT (for patients who were not going anyway).  I taught the exercises in the office, gave the family written instructions and a firm ball to use.  We collected data in follow up and the results were great.  We surveyed 43 patients, 36 of whom did the exercises at least once/week or more.  Results revealed that 78% had reduced muscle tension, 22% had reduced headache and 30% just felt better.  The more the kids actually did the exercises, the more benefit they reported.   I demonstrate the exercises,  give out instructions and balls regularly for those who would benefit, and for those who actually do the exercises, it is very helpful. The balls we used are called ‘Pinky’ balls, firm like a lacrosse ball, inexpensive, and can be found easily.  Here’s a link to the instructions:  Pinky ball Head and Neck exercises

For TTH with occipital neuralgia: Of all the previously discussed medications useful for headache, Gabapentin (Neurontin) is the one I use most often.  It is an anticonvulsant and is quite effective in dealing with neuropathic pain anywhere in the body. So it makes sense that it would help with occipital neuralgia. Gabapentin does cause sedation and mental clouding, may lead to weight gain. 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. Pregabalin (Lyrica) can be used as well, but there is abuse potential so it is controlled substance. Generally the insurance companies require failure with gabapentin before approving Lyrica. It can be hard to obtain and I do not use it often.

In a specialty headache or pain program, there is the option of occipital nerve and trigger point injections, done with local anesthetic (lidocaine and bupivacaine +/- steroids). IN TTH, the occipital nerve may be inflamed. Trigger points (areas within muscles that are very irritable) will contribute to tension-type headaches and myofascial pain.  The areas around the greater occipital nerve, as well as any trigger points in the upper cervical, trapezius muscles are 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 neuralgia and headache.   This procedure is done in a series of 3, spaced 4-8 weeks apart.  I usually encourage them to try it at least twice to evaluate whether it is helpful. Some patients have significant improvement with this procedure; some have no benefit at all.  It is generally well tolerated.

I am actually amazed at how well the teens do with this procedure. They are in my office with a parent, we do a breathing exercise throughout the procedure, and only do as many injections as they can tolerate. Even my most needle-phobic kids can do it, mainly because they cannot see what I am doing and are distracted by the breathing exercise. After we complete the injections, I insist they go to the ‘spa room’, lay down on our Biomat (like a large heating pad) in dim lighting for 15-20 minutes with relaxing ambient sounds and aromatherapy, and drink a Gatorade. Many fall asleep and are very relaxed when they leave. I know we are very lucky to be able to offer this kind of experience.  I think it actually increases the therapeutic benefit of the procedure.

In my next post, I’ll talk about appropriate rescue medications and treatment for underlying anxiety, which often needs to be addressed for kids with tension-type headaches.

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.