Introducing……… New Daily Persistent Headache

In this post, I am going to introduce you to another primary headache, new daily persistent headache (NDPH). This primary headache is not often seen in primary care, but I think our clinic population has about 25% of teens with this diagnosis.  There’s a good reason why a referral to a specialty headache program is important for these patients.

Imagine being a 13 year-old girl, just getting over a viral illness, and suddenly finding yourself with a constant, unremitting headache. At first you and your family think, it will go away soon, probably related to having just been sick.  But it doesn’t go away………….. for months or years.  That’s NDPH.

NDPH is an unrelenting headache that develops rapidly, with the person often knowing the exact day when it began, and having a continuous headache from that day. It often happens in a person with no past history of headaches. It neither a migraine or tension-type headache, but begins as a new headache. This is a very difficult headache for patients and families as it often does not respond to treatment.  It is called Persistent because the average length of this headache can be up to 3 years, or more. Incidence is reported at 2-4% of patients with headache, but this is most likely underreported, as the headache is often unrecognized for what it really is. It is seen in both adults and adolescents, but more frequently in teens.

NDPH is characterized by:

  • appearing without warning;
  • often following a viral illness, several concussions, or for no reason at all;
  • Constant headache that lasts for more than 3 months from onset (within 3 days);
  • At least 2 of these: felt on both sides of the head; feel pressing or squeezing (not pulsing); mild to moderate pain; not worsened by routine physical activity;
  • Both of these: light or sound sensitivity or mild nausea AND NOT moderate or severe nausea/vomiting;
  • All other reasons have been investigated and ruled out.

For some patients, there can be migraine-like symptoms, such as light and sound sensitivity, and nausea. For some, there can be tension-type headache symptoms, such as mild-moderate pain, non-throbbing on both sides of the head. NDPH does not respond to the usual headache prevention medications or the usual rescue treatments and medications.  Unfortunately, many patients can become disabled with NDPH.

So this teenager comes into your office, with the complaint of constant headache for the past few weeks. What do you do? First you rule out a secondary reason for headache, perhaps do some labwork (CBC, chemistry, B12, thyroid, celiac, etc), brain MRI, thorough patient and family history and physical, making sure there’s nothing else going on. The diagnosis of NDPH is a diagnosis of exclusion.

Once the secondary generators have been ruled out, you think about the primary headaches. Migraine and tension-type headaches generally start as episodic, not constant or chronic. So even with a strong family history of migraine, that’s probably not what this is.

So it’s a constant headache, moderate in pain (though with some spikes of more severe pain), probably associated with environmental sensitivities and nausea. It’s a terrible diagnosis. You have to tell the family that the usual headache treatments and medications don’t work well, that there is really no cure except time and adherence to a multidisciplinary approach to care and wellness.

And then you refer them to a specialty pediatric headache program because the family and you will need all the support you can get. In the meantime, you help them work on lifestyle- good sleep, hydration, healthy diet, and staying active.

As you can imagine, this is quite difficult. It is especially hard when there really doesn’t seem to be a reason (virus, too many concussions). In my experience, when there does not seem to be an identifiable cause for the NDPH, these particular families have a VERY hard time coming to acceptance and embracing the multidisciplinary approach. They are always ‘searching for a reason’, which can often send them down some unhealthy and unhelpful rabbit holes. That’s why you send them to a pediatric headache center, where this diagnosis is well known.

The key here is early identification of NDPH, as soon as you suspect it is not a standard primary headache. Delays in diagnosis often lead to unnecessary medication and treatment trials, increased frustration and desperation on the part of the family, and an increased level of disability for the patient.  This is a real problem without an easy answer.

I know from personal experience that partnering with the family, through all the ups and downs, makes a difference in outcomes and level of disability. You stick with them, gain their trust, and offer lots of support.  One thing I will tell my patients in particular is that ‘I believe that their headache will resolve someday. I don’t have a crystal ball to say when, but I believe they will get better. And I have seen many patients who really did get better’.  This can help give them hope.

Hope is so important and powerful. I often refer to my colleagues and myself as chief cheerleaders for these families. They’ll say ‘we know there’s not much out there that can help, but we come in anyway, so you can give us hope’.   Recovery is possible with hope.

I will further review options for dealing with the patient with NDPH in my next post.

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.

When migraine turns chronic

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

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

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

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

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

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

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

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

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

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

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

All about the Migraine….part 2

So you have identified one of your patients as having migraine. Now decisions have to be made about management. Important points to consider are: frequency of migraine, intensity of pain and/or associated symptoms, triggers, and lifestyle factors.  Unless the patient is presenting with frequent or intractable migraine several times/week, the first things to review with the patient and family are basic headache-healthy lifestyle guidelines.

What are the most important lifestyle factors to consider in migraine (or any headache for that matter)? Hydration, diet, sleep, exercise/activity, and stress management.  Helping families understand what they can do to reduce migraine is empowering and creates a sense of partnership.  Some families may want to go straight to daily preventive medications, but most would rather start with the basics.

Suggested recommendations:

Hydration is probably the most important aspect of preventing migraine in kids and teens.  I usually recommend that patients drink the equivalent of their weight in kilograms (50kg = 50 oz), or half their weight in pounds (100lbs = 50 oz). This works for patients up to 80kg; above that weight, I will recommend 80-100oz/day.  I have found that families need a real number to aim for, rather than just saying to ‘drink more’, which greatly improves compliance.  I strongly encourage bringing a refillable water bottle to school daily, and bringing it home empty. Most bottles are 20-24oz, and kids who drink during school generally meet their hydration requirements.  Appropriate hydration includes water, seltzer, electrolyte-rich fluids, milk, juice, and do not include caffeinated beverages or soda. Neither sugary nor sugar-free sodas are great, because both high sugar and artificial sweeteners are migraine triggers. If the kids balk at water, a little juice added can help. Some schools do not allow water bottles, but a note from a provider will help (or it can be a part of a 504 education support plan).  I encourage using electrolyte-rich fluids around heavy athletic activity or during migraine, but not as a daily beverage- can lead to obesity or dental caries due to sugar.

Diet is important in a variety of ways.  For some migraineurs, there are foods that can trigger migraines and need to be identified and avoided. There are lists of these foods readily available and I will attach a list here (Headache Elimination Diet).  I tell kids that as a person with migraine, they have to be a detective for their triggers, again empowering them to have agency in their own health. In addition, ensuring regular meals- breakfast, lunch and dinner plus snacks- is key in preventing migraine.  Meal skipping can trigger migraine and many patients have learned this the hard way. Also a diet as varied and nutritious as possible is just good for health.  Some children are very selective (‘picky’), and can be lacking in essential nutrients.  Kids who eat a ‘beige’ diet, eating few if any vegetables or fruits, probably would benefit from a multivitamin.  A common migraine supplement is vitamin B2 (riboflavin) and children with limited diets would benefit from a B complex vitamin.

Getting enough sleep is crucial in the prevention of migraine.  Depending on their age, children and teens need between 8-12hours of sleep per night.  In addition to getting to bed on time, using good sleep hygiene, including bedtime routines and managing time on electronics, is key to adequate sleep.  In our busy, over-scheduled lives, prioritizing sleep can be difficult.  Families just need to understand how inadequate sleep can affect the migraineur.  This might mean that the tween avoids sleepovers, as she knows that a migraine is likely the next day. Or that strict limits on electronics- using phone, tablet, video games, etc- are consistent and enforced. There are many barriers to getting enough sleep, including heavy homework loads, multiple sports or other activities, as well as early start times for high school.  Many communities are beginning to address the start time issue, but families are encouraged to be proactive in setting limits on participation in activities. Inadequate or disrupted sleep is a common migraine trigger.

I’ll continue to review lifestyle factors in the next post. Most of the recommendations apply to all headache types for the most part and are worth a discussion with all families.

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.

 

I have a headache!

 

So your young teenage patient comes in the office with a primary complaint of headache. This is something that happens very frequently.  In fact, headache is in the top 5 diagnoses for children and teens, occurring in 75% of teens and 25% of younger children.  Kids miss school, lose time with friends and in activities.  Family life can be significantly disrupted by headaches.  Everyone in the family has decreased quality of life, and concurrently increased environmental stress.

And with this complaint, there are many things to think about. Is this a primary headache, such as migraine, tension-type, or new daily persistent headache? Is this a secondary headache, such as a headache caused by something serious (brain tumor, brain bleed or meningitis), or less serious (allergies, sinus infection, virus)? Is this the first time your patient has complained of headache or the 20th time? Are there any pre-existing comorbid conditions?   The most important thing is to distinguish between primary and secondary headaches, and then go from there.  You absolutely don’t want to miss that secondary headache diagnosis.

You decide that your patient is constitutionally well, has no signs of serious illness, injury, or viral infection. This is most likely a primary headache. And now the fun begins!

Being a provider for patients with headaches is like being a detective. And it helps if your patients and families join you in your detective work.   I always talk with families about their role, especially with data collection, because good data helps guide care and interventions.  It also encourages the partnership between provider and family, building that relationship.

One of the hardest things about being a headache patient is that it’s an invisible affliction.  Nothing is more important to a headache patient than having a provider who understands, is supportive and knowledgeable about their health issues. It’s the ultimate key to improvement in health outcomes and lifestyle changes.