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.

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.

Daily medications for migraine, part 1

So we have talked about lifestyle habits to prevent migraines, all the things your patient can do to prevent migraines. But your patient is still having frequent migraines or the migraines are significantly impacting the patient’s functioning.  When do you consider adding a daily medication to prevent migraines? The mark I use for deciding when a preventive medication is needed is one migraine/week.  For me, that is when the conversation needs to start.   Any less than that, the kids may be unnecessarily exposed to medication effects and side effects.

And not every kid/teen needs to take a daily preventive medication, even when they have 1 migraine per week. It really depends on how much impact that migraine is having. Are they missing school with every migraine?  Does the migraine last for several days, leading to even more missed school?  Are they missing out on desired activities, like sports, scouts, music or dance? Are they missing out on time with friends and family? Does the patient want to try a daily medication? Is the family in favor or opposed to it? It is a choice that is made after discussion with everyone involved.

However, when the patient is having more than 1 migraine per week, it is a good idea to consider a daily medication, as it is likely that migraine is taking a toll of the patient and family. What you choose depends on the age of the patient and what other issues they are challenged with. Do you start with a prescribed medication or supplements/vitamins?

Supplements:  If you and/or the family are on the fence about starting a medication, a nice intervention to add is a supplement known to help headaches.  We commonly will recommend magnesium, riboflavin or Coenzyme Q10.  I always advocate for using a single product at a time, taking it for at least 3 months and evaluating effectiveness.  Again, you need to keep the good data.   There are many combination products on the market. I have seen one which contains 10 supplements in one tab!  The problem with combination products is that you are unable to figure out what exactly is helping, therefore are ‘married’ to a particular supplement formulation.  And you know that’s going to end up being expensive. A good quality supplement, which can be obtained at the local pharmacy, is totally adequate to try and there are often opportunities to save money on them. These supplements are well tolerated and can be effective.   Here’s a link: Supplements That Help Headaches

One supplement to mention is butterbur, a shrub grown in Europe and Asia, and used as a migraine preventive and for allergies. The concerns with butterbur are that it can be toxic to the liver; the unprocessed butterbur contains chemicals called pyrrolizidine alkaloids (PAs), which can cause liver damage. The only butterbur product you should use is labeled ‘PA- free’, meaning the PA has been processed to remove it. It is unlikely that you would ever find butterbur not labeled this way. Petadolex is the most common butterbur on the market and is PA-free. There are side effects as well such as belching and GI issues, and allergy and asthma, and people allergic to ragweed, chrysanthemums, marigold and daisies should avoid it. Butterbur has fallen out of favor due to report of hepatic issues, though a recent paper has refuted that claim. I have a few patients on it, tolerate it well, and find it helpful, when prescribed medications have not been. I check their LFTs yearly just to be sure.  I mention it here to further your knowledge, as Dr. Google will be sure to mention it, when your families are searching for migraine remedies.

Medications: The aim of daily preventive medication is to decrease the frequency, duration and severity of migraines. Other benefits can include improving responsiveness to the rescue medications and preventing migraines from becoming chronic (vs. episodic). Your choice of medication depends on the patient’s age, medical history/comorbidities, and particular circumstances. Generally all migraine medications for kids and teens are dosed low and titrated up in dose as needed and tolerated.  Groups of medications commonly used for migraine prevention are antihistamines (cyproheptadine), tricyclic antidepressants (amitriptyline, nortriptyline), anticonvulsants (topiramate, zonisamide, gabapentin), beta blockers (propranolol) or calcium channel blockers (verapamil).

Before we talk about the pros and cons of each group of medications, I would like to bring up an interesting research study you may or may not be aware of. A few years ago, the headache program at Cincinnati Children’s Hospital undertook a multi-site double blind medication trial, comparing amitriptyline, topiramate and placebo, for the prevention of migraine in children ages 8-17 years, the CHAMPS study.  The headache program I work in participated in this research project. The study was unusual because it was double blind (no one knew which medication each subject was taking), and it included placebo as one of the treatment arms.  The research study was terminated early because the findings showed no difference between the 3 treatments arms.  The 2 medications both had more side effects than placebo, and there were also serious adverse events in each group. They conclude that “the risk to benefit profile of the two most commonly used preventive medications does not suggest their use as first-line intervention for pediatric migraine.” Basically, they found that placebo was as good as or better than medications and had fewer side effects.  Here’s link to their results: CHAMPS clinical trial publication

This of course presents a dilemma to pediatric providers caring for kids with headaches. You can’t exactly prescribe a placebo and with the family knowing you are doing that, it negates the placebo effect. It is certainly another reason to continue doing research into pediatric headache, and to encourage our families to participate.  We are doing a lot of research at our center, brain imaging, studies looking at the psychological factors impacting episodic and chronic pain, and clinical protocols.  Our families are very interested in participating with research, as they see the value for themselves and for others.

When thinking about daily medications, we all need to be aware that studies are often not done on the pediatric population, just extrapolated from adult data. This is all the more reason to be cautious in prescribing, and encourage appropriate lifestyle measures to decrease the likelihood of migraine.

In my next post, I will review commonly used migraine preventive medications. Some pediatric providers may not feel comfortable starting a daily migraine preventive. But the judicious use of a low dose of medication may really help your patients with their migraines. It may prevent episodic migraine from becoming chronic, and prevent a functioning patient from becoming disabled.  These are all worthy efforts.

Migraine medications to the rescue…..adjunct and combination therapies

There are 3 groups of medications that are used to treat a migraine attack: migraine abortives, analgesia, and adjuncts.  We have covered the migraine abortives (those medications specifically designed to stop the migraine attack) and analgesia (used to reduce pain) in the past 2 posts.   There are several medications that are used either in combination with others to treat the migraine or to treat other symptoms that happen with migraine.  These medications are referred to as adjuncts in migraine therapy, and are often used in combination.  Again, developing an individualized rescue plan is the key to living with migraine, rather than suffering from migraine.  Patients often need several medications for an effective rescue plan.

Adjuncts

Adjunct medications are those that are given with analgesia to complement and enhance the effect and treat other symptoms, such as nausea, dizziness or insomnia.  A classic combination is an NSAID with ondansetron (Zofran), or metoclopramide (Reglan) =/- benadryl, or prochlorperazine (Compazine). I will often encourage taking an adjunct with analgesia at the same time, and if appropriate, with their triptan.

The most common adjuncts are antiemetics, those medications which treat nausea associated with migraine. Antihistamines, such as diphenhydramine (Benadryl), meclizine, and/or hydroxyzine (Atarax) are useful in combination with NSAIDs.  There is the added benefit of drowsiness, to help facilitate restorative sleep.  Ondansetron is also useful for nausea, generally does not cause drowsiness.  Compazine and Reglan are seen as primary agents for treating migraine as well as treating nausea.  The side effects associated with these 2 medications can be avoided by using them with Benadryl.  Dosing is based on weight and age appropriate.

Another option often used in the ED is steroids, such as dexamethasone.  If a patient has had this in the ED, they could use this as an outpatient rescue as well.  Oral magnesium is sometimes used as a rescue medication too.

Treatment Combinations

Many patients develop a migraine rescue strategy, over time and with experience, that involves a combination of medications.  It is always a very individual plan and usually discovered by trial and error.  They might have reasonably good results with a triptan plus antiemetic, or triptan plus analgesia. They may have the best results with an ‘attack pack’ of 3 medications taken together, such as sumatriptan, naproxen and Benadryl.  In cases when a triptan is not effective, NSAID plus antiemetic is a good combination.

The key is to work with the family, figure out what works best, and then BE PREPARED for the migraine to happen.  For younger kids, their parents should always travel with a dose of each of their rescue medications.  They need to have several doses of each medication with the school nurse as well. Older teens can have a prepacked plastic bag with 1 dose of each medication that they can carry with them outside of school.  (Make sure it’s labelled, for obvious reasons).  Most high schools do not allow for self-medication. It is well worth it for the family to have a good relationship and understanding with the school nurse; that when the teen comes to the nurse’s office, they can get their medication promptly and have a chance to lie down and nap for up to 30 minutes at least. Having a clear plan communicated to the school nurse is so helpful.  The workload of our school nurses is tremendous, and having a collaborative relationship with them will make rescue therapy much easier and effective for the kids.

Complementary rescue remedies

In addition to the medications we have talked about, there are a number of complementary interventions that can really help resolve a migraine.

  • Aromatherapy: using an essential oil, such as peppermint, lavender, ginger, or a specially formulated blend (M’Grain from Young Living products) topically, gently massaged on the temples or behind the ears
  • Ice/cold (or heat) applied to the forehead or the neck
  • Gentle massage to the neck and occiput or frontal/temples
  • Anything that activates the relaxation response, such as a CBT or biofeedback exercise, breathing technique, using a relaxation/meditation app, soothing music.  My favorite is the Insight Timer app, so many options and free.

Final rescue thoughts

Having migraine is challenging for the whole family. Migraines often occur at the most inconvenient times, often out of the blue.  It’s important to remember that stress is a trigger for most patients, and stress is not always negative. Positive stress, such as excitement about an upcoming vacation trip, can also trigger migraine.

I also cannot emphasize enough how important it is to treat the migraine promptly- hit it hard and fast- for best results and resolution.  Giving parts of a rescue plan, half-doses spread out over time, usually just prolongs the episode and makes it more difficult to resolve. And there really is no point in prolonging the agony, especially when it is your kid’s pain.

Being prepared, having rescue medications, and extra electrolyte-rich hydration fluids can go a long way in turning a migraine episode from a disaster into a blip on the radar.

All about the Migraine…. part 3

In the previous post, I talked about the important lifestyle factors and strategies of hydration, diet and sleep. In this post I will discuss exercise/physical activity.  Again these are basic lifestyle strategies that are appropriate for all headaches, but can be particularly important to migraineurs.

Exercise or physical activity is vital to healthy functioning for everyone.  For some of our patients, it can be challenging to get active.  And if you have a migraine, the last thing you want to do is exercise.  But getting exercise on a regular basis is an excellent way to prevent migraines. It physiologically improves your cardiovascular system, provides stress relief and releases endorphins, and when done with others, exercise can be a positive social experience. All of these aspects contribute to a healthier lifestyle with fewer migraines.

Our basic recommendation is 30 minutes of vigorous activity, 3 times per week. This can be sports practice or games, dance class, going to the gym or a run, or playing outside with the family dog. Kids can be encouraged to make the active choice.  That can mean taking the stairs instead of the elevator, walking up and down every aisle at the grocery store, or parking (or encouraging their parent) the car far away from the store entrance to sneak in some extra steps.  We all need more exercise, and the more the family participates, the easier it is for the teen to join in. No teen wants to be the one who is singled out for exercise.  Families or friends can get activity monitors and set up challenges- see who can get the most steps in a day, weekend or the whole week. There are endless possibilities and options. The key is to just get started.

For those kids who are inactive, this might seem daunting. They may have stopped doing their sports or activities because of migraines, and are worried that activity will make them worse. This is a situation where pacing is really helpful. Basically activity pacing is the slow return to exercise, working toward being able to tolerate increased intensity and time in a vigorous activity. Often, I will ask a teen to start to get more active and describe how to do it, slowly and methodically. On the next visit, he report that they ran a mile once, had worse headaches and stopped.  (Not exactly what I recommended!)  It’s a hard concept to explain. I found some excellent You Tube videos, done by a teen girl with chronic pain, with great explanations.  The series of 5 videos is called Pacing: Your Superpower against chronic pain, and here’s the link:  YouTube videos on activity pacing.  I encourage my patients to check them out and while not every suggestion will apply to them, they can gain better understanding of the concept and make an appropriate plan for themselves.

One of the keys to establishing an exercise habit is convenience. Whatever activity is chosen, participation has to be easy to achieve: going to a neighborhood gym rather than the one across town; walking around the block or to and from school; carpooling with a friend to exercise/dance class, etc.  The strategy of convenience makes it easier to establish and keep a good habit, and then it just becomes a part of daily life. (Read more about strategies for establishing good habits in the book “Better Than Before” by Gretchen Rubin.)

Finally, I am always asked about what is the best exercise to do.  My answer is always the same: Do the activity that you like and that you will actually do.  Of course, there are a few things to avoid, like doing inversions in yoga during a migraine.  And I am biased against high impact sports, where it is more likely to result in concussion (a potential disaster for migraineurs).  But any activity that brings you joy, satisfaction, a good feeling, a hit of endorphins, is the right exercise.  Just put the phone down and get moving!

All about the Migraine…. part 1

The 3 most common subtypes of primary headaches commonly seen in pediatric patients are: migraine, tension-type, and new daily persistent headache. Children often have a combination of types, such as chronic mixed type headache, which generally combine migraine and tension-type headache. All primary headaches present differently and are often treated differently.  Migraine is a well-known type of headache, so I will cover that first, in a number of posts.  There are also migraine variants,  particular to children, such as abdominal migraine and cyclic vomiting syndrome.

Migraine is a neurologic disorder, characterized by headache attacks. Headaches are episodic or chronic, are recurrent, can last from 4-72 hours, with moderate to severe throbbing pain. Migraine pain occurs due to dilation and inflammation of the intracranial blood vessels, which irritates the adjacent nerves.  Pain can be felt in one location, such as behind the eyes or temples, or one-sided, or everywhere (holocephalic). Pain can occur suddenly or be preceded by warning symptoms, called an aura.  Along with head pain, patients can experience nausea and/or vomiting, photophobia, phonophobia, osmophobia (sensitivity to smell), pallor, lightheadedness or dizziness, visual changes (blurred vision, loss of vision, seeing colors), hearing changes (tinnitus), paresthesias, focal numbness, fatigue, sweating, and scalp sensitivity (allodynia). The only constant in migraine is that every migraine patient experiences their migraines differently- different location, constellation of symptoms, triggers.  Diagnosis is made based on symptoms and history and in the majority of cases, migraine is clearly identified.

Migraine is often found within families, passed genetically through generations.  The incidence is more common in women (17%) than men (6%). Most people have their first migraine between the ages of 6 and 25 years, so it is likely that their pediatric provider will be the first person to evaluate for migraine. Imaging is not required to diagnose migraine, especially if there is a strong family history.  However, imaging (MRI) can be helpful for presentations without family history, unusual, complex or variant-like symptoms. Most families are comfortable without imaging when there is family history of migraine.

Most migraineurs have missed school, social or sports activities, or work during a migraine, and about 50% have difficulty functioning at all during an attack. As you can imagine, having 1 migraine episode per week and having to miss 1 day/week of school, is going to have significant consequences.

The next step, after making the diagnosis, is to decide on a treatment plan.  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 migraine or reduce the incidence of migraine?  We will start to cover this topic in my next post.

Headaches in the community

Headache is one of the most common problems seen in the primary care office. It is often a chronic complaint, not easily managed, and often an unsatisfying experience for families and providers.  You can’t cure headache like an ear infection, it will always come back in some form or another.  And while headache is technically a neurological problem, at its heart, headache is a chronic pain problem. It is not as glamorous or interesting as many neurological conditions. Many neurologists are not as interested in headache as they are in other conditions. Patients and families are often challenging and the issues are often multi-factorial, comprehensive and complicated.  Chronic pain is a field that takes a certain mindset and approach, not for the faint-hearted. I believe that a multidisciplinary wellness approach to care is best, and our job is to guide the families to adopt that approach.  This is time consuming, requiring a lot of counselling and coaching, to achieve good results, and most importantly to prevent disability.

Fortunately, for those of us who work in the headache field, there are many wonderful patients and families, more than happy to work as a team to achieve good results. You can have your chronic migraine patient with several comorbidities including inadequately treated psychiatric issues and significant disability as your first patient of the day. Then you can have a patient with episodic migraine or menstrual migraine, with many family members with migraine, has learned their triggers, has a rescue plan, and is doing well overall. It’s really a mixed bag in the headache world, which makes it a bit different than the usual chronic pain patients, especially in pediatrics. It is also more enjoyable.

I think the most important thing is being able to accurately make the diagnosis, identify appropriate treatment, and obtain buy-in from the patients and families to accept the multidisciplinary approach to care.  Since I work in a tertiary care outpatient clinic setting, our patients have already been evaluated, tried some medications or treatments, and have not had success. Patients may have had inadequate medication trials, been given incorrect diagnoses and treatments, and establishing trust is difficult. In these days, instant gratification is desired, and this is just NOT a hallmark of headache care. Daily medications can take a month to see effectiveness (or not). Lifestyle changes take time.  Learning cognitive behavioral skills take a while to become effective.  Establishing a healthy headache lifestyle along with adequate treatment options is a marathon, not a sprint. There’s a lot of trial and error.  Without the families’ trust, this journey is made even more difficult.

For the community provider, having some good baseline knowledge of headache, is a great starting point.  In the next posts, I will review the primary headache in pediatrics. Learning to recognize the specific headaches and common treatments, both preventive and rescue, is the bread and butter of headache medicine.