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 strategies

I have reviewed factors contributing to tension-type headaches, as well as some preventive strategies.  In this post I will cover appropriate rescue medications, and talk about treatment for underlying anxiety, which often needs to be addressed for kids with tension-type headaches.

Analgesia is a key part of a rescue strategy for TTH. Non-steroidal anti-inflammatory drugs (NSAIDS) are the mainstay of headache analgesia. The side effects are GI, such as gastric distress, nausea, ulcer, hematologic, such as bleeding disorder or platelet dysfunction, or related to allergic reaction.  Any of the NSAIDS can be effective in treating a tension-type headache.  Treating a TTH  as soon as possible is the key to success.  I talked about this class of medications more in depth in the blog post “migraine medications to the rescue…analgesia”.  Ibuprofen and naproxen are the most commonly used NSAIDS and are effective for those who can take them.  Some people will also use diclofenac, sulindac and even ketorolac.

For patients who cannot take NSAIDS, acetaminophen (Tylenol) is useful and usually well tolerated, with adult dosing for teens of 650-1000mg q4-6h, weight- appropriate dosing for younger kids. There are many formulations- suspension, chewable tabs, dissolve tabs, regular tablets and extra strength tablets.

Aspirin can also be used, but should be used in a limited fashion due to the risk of Reye’s syndrome.  Another Excedrin product, Excedrin Tension Headache, similar to Excedrin migraine, but does not contain aspirin can be used as well.  Each coated tablet contains 500 mg of acetaminophen and 65mg of caffeine. Of course you wouldn’t want to use this in the evening.

For all analgesia, patients should not take them for more than 2-3 days/week to avoid medication overuse headaches.

Other medications: there are a few other medications that can be used for treating other symptoms associated with tension-type headaches. These would include anti-emetics like ondansetron for nausea or an antihistamine, like Benadryl or hydroxyzine, for dizziness. A muscle relaxant could also be a rescue medication, such as tizanidine, but quite apt to make them sleepy.

Complementary rescue strategies:  In addition to the medications we have talked about, there are a number of complementary interventions that can really help resolve a tension-type headache.  In addition, reiki, acupuncture and other complementary therapies can certainly play a role in reducing stress and anxiety, which often trigger tension-type headaches. For some patients, doing these strategies can treat a TTH, and they do not need to take any medication.

  • Aromatherapy: using an essential oil, such as peppermint, lavender, or ginger used 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, or breathing technique, using a relaxation/meditation app, soothing music. My favorite is the Insight Timer app, so many options and free.

Stress and anxiety are frequent triggers of tension-type or stress headaches. Many of us carry our cares and worries in our neck and shoulders. During stressful times, the trapezius and paracervical muscles (which encompass our head) tense up around our heads, squeezing the occipital nerve in particular bilaterally, and triggering headache.  Relieving the pain involves getting these muscles to relax. I refer you to my blog post “stress and migraines” for more information about this and appropriate strategies.

When I have a patient who demonstrates or reports having significant anxiety, I know that this needs to be addressed in order for the teen to start having less frequent TTH. This is not always a welcome message, especially when I encourage them to get some professional help. It is not always easy to bring up, but so necessary.  There are many ways to intervene, including medications, but having a good counselor to talk to and learn CBT skills from is the best intervention, from my point of view. Kids and teens actually do very well with CBT (Cognitive behavioral therapy), especially if they do their ‘homework’ and if there is buy-in and support from the family.

Unfortunately, there can be significant barriers to getting into counseling, including lack of local providers, insurance barriers, time constraints and general lack of commitment to the process.  I think finding an appropriate therapist (psychologist, LICSW) is the biggest hurdle.  The PCP can help by knowing the network of child psychology providers in the area. The website, www.psychologytoday.com, has a search feature which can help with that; just enter the zip code, and narrow the search (child/teen, CBT), and a list of local providers comes up.  I have found this to be a very valuable resource, especially when I see patients who are not from my area. I also refer families to their insurance carrier, to find providers who are in network.  I encourage families to understand that finding a therapist is a process, which may involve many phone calls and leaving messages. It can be quite frustrating.

Concerning medications, I have an informal rule that I will not start an anxiolytic medication unless there is counseling set up or actively being pursued.  I think it is important to send the message that there is work to be done to manage anxiety, and the more work the patient is willing to do, the less medication (and side effects) is needed.  Also SSRI/SNRI medications are not without risk, including the black box warning of suicidality in the young and teenage population.

There are definitely times when both counseling and medication is needed, but in my opinion, the therapy is most important. Why? Because therapy/CBT can help our young patients develop the skills and resilience to face the challenges of life. Kids and teens need to develop their inner resources to deal with their quickly changing environments, without becoming overwhelmed or despondent, or falling into other unhealthy coping strategies, such as addiction. As providers, we owe it to them to steer in the right direction as best we can, to speak up when we think psychological help is needed, and to support our families in their healing journeys.

Off the soapbox now……………

My next posts will be about another primary headache, new daily persistent headache (NDPH), a very challenging headache diagnosis. Stay tuned………

 

 

 

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

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.

 

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.