Gratitude

So it’s been just 1 year since I started this blog, posting regularly every 2 weeks. That was one of my intentions for 2018 and I am so glad I made it happen.  I have learned a lot more about headache management in the process.  I also learned that I do actually know a lot about it already.  Funny how that happens…..

My intentions for 2019 are to keep posting new content, maybe invite some guest writers to contribute. I also want to explore other avenues in the academic world and social media arena to get the word out to other pediatric providers about taking care of kids and teens with headache. To that end, I will have a poster at the National NAPNAP conference in March 2019 in New Orleans.  I have also started using Instagram (vkarianpnp), though I really do not know much about how to use it effectively. That will be another learning adventure. I am hoping my younger colleague will help me out : )

For this post, I thought I might present a list of a few of my favorite things, common occurrences that relate to taking care of kids with headaches. These examples are composites of several patients, not anyone specific.

Here they are, in no specific order:

  • A teen with new daily persistent headache (NDPH) for years comes in for a visit. This patient has attended school daily, engages in a headache-healthy lifestyle, physically and socially active. She is completely functional, working hard and just waiting for this headache to break. She has been working hard on self-care and turning on the relaxation response regularly. Today for the first time, she reports having 5-10 minutes of headache-free time several times/week. We have all waited a long time for this to happen, because it means the start of the end of her NDPH!
  • Tween migraineur who has struggled with an effective rescue plan comes in for a visit. They report that finally we have managed to develop a successful migraine rescue plan, which works consistently. We had gotten creative and it worked!
  • A college freshman comes in for her winter break visit. She had many fears about being away from home with migraines, despite my reassurance that she could handle it and would have more time for self-care. She reports to me: ‘You were right….college has been easier than high school. I didn’t believe you but now I know it’s true.” Score!
  • 15 year-old teen girl, with frequent migraine and difficulty managing a headache-healthy lifestyle, comes for a visit. She reports that her migraine headaches are occurring just once/week, instead of multiple times. What made the difference? “Well I finally figured out that lots of hydration actually works”, she says (after years of trying to get her to drink enough)!
  • Eighteen year-old male patient disabled by headache and mental health issues comes in for follow up. We have tried many medications, approaches such as partial programs, healthy lifestyle approaches. Headache is completely refractory; he is disabled and unable to function, not going to school. I have do not have much to offer, since the mental health issues are paramount, and he is unwilling to go inpatient for care. I ask why they have come in, when I feel I have nothing to offer. His mother responds “because you always listen, are willing to try anything, and you obviously care about us.”
  • Teenager with NDPH has tried everything under the sun without relief of symptoms. She undergoes a short duration lidocaine infusion and we speak on the phone 1 month later to check on the outcome. She reports no change in headache pain (I am disappointed). Then she reports that her mental fogginess is greatly decreased, she was able to get through her final exams without being totally wiped out, and has more endurance and energy. The first of many such reports from patients after lidocaine infusion and unexpected. There was no change in headache pain but other symptoms are better, which helps them function better. A small victory!
  • Another teenager with NDPH for 6 years and episodic migraine, who has had nothing but side effects from every medication ever tried, no positive effect with lidocaine infusion, and reluctant to try anything else comes for a visit. I propose trying occipital nerve and trigger point injections, because why not try a ‘Hail Mary’ pass at this point. We do it and when she comes back in 6 weeks, she reports the constant headache is no longer constant (still daily). And after 3-4 procedures, the chronic headache is pretty much gone until the effect of the injections starts to wear off. She still has migraine but had no ED visit for 9 months- a record. Who knew it would help?
  • Tween girl with chronic tension-type headaches comes for a regular follow up visit. She has considerable neck and shoulder tightness and at her last visit, I taught her the ‘Pinky ball’ exercises to self-massage and stretch. She was a reluctant participant at the time but her mother was interested. She reports today that her TTH are much less frequent now; she is using the pinky ball exercises every night before bed and thinks it has helped. Her mother nagged at her to do it at first but once she started to feel better, was doing it on her own. Tweens are such a tough audience!
  • Twelve year-old boy with chronic mixed-type headache, significant anxiety, ADHD and school avoidance, seen briefly when he stops by clinic during another visit. He had become very disabled, not going to school at all, and just spent 4 weeks in a pediatric pain rehabilitation program to get back in the game. His time in the PPRC was tough, changes were met with much resistance, and there were doubts whether he could maintain recovery when back in his home routine. He reports that he is back in school and going every day, saying he “would rather be in school than in the rehab program and does not want to come back”. The coordination between the PPRC and school resource personnel and the accommodations that were made allowed him to restart school in a positive way. He still had chronic headaches and anxiety but had learned how to manage and cope. Fingers crossed that it sticks!

Taking care of kids and teens with headache is a challenge. You often have to get creative to get improvement, looking at appropriate developmental approaches. You also have to understand that not everyone improves, due to many factors outside of your control.  The interplay between headache and mental health often slows progress. But sometimes improvement happens when we least expect it. That makes the work worthwhile.

Let me know if there are any topics you would like to see in the blog. Always open to suggestions.

Happy New Year!

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………

 

 

 

Talking about Tension-type headaches

Starting this month, I am going to move on from migraine and start to review another primary headache, tension-type headache (TTH), commonly seen in children and teens. In earlier blog posts I discussed lifestyle factors for good headache hygiene.  All of those recommendations can be applied to any headache type, including TTH, and I refer you to those earlier posts for specific recommendations.

Tension-type headaches are the most common type of headache, but generally less disabling than migraine or some other headaches. The pain can be mild to moderate, often described as being like a band around the head, pressure, dull and aching, and involving both sides of the head. Tension-type headaches usually come on slowly and can sometimes last for days. The headache is caused by muscle tension in the scalp, neck and upper back which tightens the blood vessels and causes pain. There is also irritation and changes in the blood vessels that make the pain feel worse and more severe than you would expect from muscle tension.

Some teens also have neck stiffness and signs of occipital neuralgia, which is described as sharp, shooting or burning pain which travels from the occiput to frontalis. The tight muscles squeeze the occipital nerve, leading to neuralgia. The neuralgic pain can be felt along the pathway of the occipital nerve and can be felt even behind the eyes. Occipital neuralgia has been described to me as a sudden and severe electric shock-like pain, brief, and can knock you off your feet.  The episodes of neuralgia can be infrequent or several times/day.  The pathophysiology of TTH is not completely clear; nociceptive input from cranial and cervical myofascial components will trigger TTH and if this noxious input is sustained, the pattern becomes chronic.  As a result, frequent TTH with/without neuralgia can lead to central sensitization, scalp allodynia, and chronic tension-type headache.

Common triggers are similar to migraine and include anxiety, depression, life and school stress, poor diet, lack of sleep, dehydration, lack of exercise and movement, poor posture, neck and upper back muscle spasms and strains, and general illness. Along with pain, kids with TTH can experience a few other symptoms such as lightheadedness or dizziness, mild nausea and fatigue. They do not usually have the array of associated symptoms that someone with migraine would experience. And while the pain is usually not as severe, TTH can also be debilitating when it becomes chronic, when there is occipital neuralgia, or when the underlying issues are not addressed.

Significant contributing factors are stress and mental health issues, such as anxiety and depression. Oftentimes, headache is the major presenting symptom, and on further investigation, environmental stress (home, school, peer bullying) and mental health challenges are revealed, either at the PCP or frequently at the school nurse’s office.  Getting to the bottom of these issues and intervening can lead to an improvement in TTH.

Learning to manage stress is the key to preventing or minimizing the suffering from TTH. When you think about your stress, where do you usually feel it in your body? Some people feel it in their gut- nausea, butterflies, GERD, abdominal pain, diarrhea/irritable bowel. Some people get short of breath, hyperventilate, feel chest tightness or even trigger an asthma or panic attack. Maybe you have emotional eating or stop eating altogether. For many people, it is in the muscles- muscle tightness or even muscle spasm.  This tightness can be in the back, such as low back pain in adults, or for many, in the upper back and neck, which can lead to headache.

So it makes sense to understand how we respond to stress and also how to decrease the habitual physical reactions to stress. We all can experience these reactions and our bodies respond instinctually ‘the way it always does’.  When stress is experienced in the musculoskeletal system and causes pain, this is often described as muscle memory. Say you have a minor low back injury and have a back spasm; the next time you feel stressed, you may respond by having a back spasm/pain.  Over time, this area of your body has become a point of weakness and susceptible to having a stress reaction. It happens differently for everybody.  This is often what happens with TTH: there is stress, then upper back and neck muscles get tight, squeeze around the skull and trigger headache.  What is important is making the connection, recognizing what stress does in our bodies, and then figuring out what to do to decrease the automatic response.  You can help your patients figure this out.

If you have diagnosed your patient with tension-type headaches, the next steps include how to prevent and treat them. The same questions apply to TTH as to migraine: Does this patient need a preventive or daily medication? What is the rescue plan? And even more importantly, what about the lifestyle factors that can trigger TTH? The questions are the same, sometimes the interventions are the same but there are some differences. We will cover this topic in my next post.