Pediatric Primary Care Case Studies (83 page)

The plan is thoroughly discussed and decided with Mr. Brown’s input. This is particularly important because the father had expressed his lack of satisfaction with the other two providers who did not schedule follow-up visits. The treatment plan you identify incorporates the goals outlined in the American Academy of Neurology Practice Parameters (Lewis et al., 2004) and the Guidelines of the National Association of Nurse Practitioners (Gunner et al., 2008) for the treatment of pediatric migraine. They include:

•   Reduce the frequency, duration, severity, and disability from the headache.

•   Reduce reliance on medication for acute migraine treatment that is ineffective or poorly tolerated.

•   Improve the quality of life of migraine sufferers.

•   Avoid overuse and escalating use of medication for acute migraine treatment.

•   Educate patients to help them self-manage and self-control their migraine headache.

•   Reduce headache-related distress and emotional symptoms in migraine sufferers.

Treatment Options

In order to develop a treatment plan, the options need to be explored with the father. First, it is important to assess the degree of headache disability. The PedMIDAS tool was developed at Cincinnati Children’s Hospital and is available online at
http://www.cincinnatichildrens.org/svc/alpha/h/headache/pedmidas.htm
. The scoring information and PDF of the document are available at the Web site.

The next step would be to discuss nonpharmacological approaches because the family has not had a good experience with medication (see
Table 20-3
).

John’s PedMIDAS score is 24, indicating a mild disability from the headache. A headache diary has not been done before, so you explain the reasons for the diary to Mr. Brown. Headache diaries can help identify triggers, allow for the child to express the headache symptoms, and help identify whether the treatment regimen is working. Headaches can be precipitated by different things including sleep, nutritional intake, physical activity changes, hormonal changes, lights, types of food, and stress. Minor stress can be missed by the parent, and a headache diary can help the child point out the problems to the father, who will share in the responsibility of keeping the diary.

Mr. Brown and John are interested in increasing John’s amount of daily physical activity; however, it was more problematic for Mr. Brown because John is with a grandmother who is very protective of the child and does not allow playtime outside of the house. You ask Mr. Brown how he thinks he could increase John’s daily exercise, and he decides that he will play catch with John after dinner.

Regular meal times, good hydration, and avoiding caffeine are discussed. Mr. Brown feels that John gets enough fluids in school, but he says he will talk with the teacher
about allowing extra fluids during the school day. You give Mr. Brown a list of caffeine-containing fluids, including sodas. After further discussion, Mr. Brown decides to try relaxation techniques because this is something he feels he could do with his son at home. The family is introduced to the technique in the office setting.

Pharmacological management of acute headache involves taking the medication as prescribed in the right dose at the onset of the headache.

Teaching Mr. Brown to identify and treat the pain early is a key point to abort the pain. John needs to have the medication with him so he can take it within 20–30 minutes of onset of the headache (Lewis, 2007b). You give Mr. Brown a note for the school. You discuss changing medication from Tylenol to ibuprofen at 10 mg/kg. Ibuprofen is an effective first line drug for migraine (Gunner et al., 2008; Lewis et al., 2004). Mr. Brown is happy about a change in medication.

Mr. Brown raises the issue of complementary medications such as feverfew, ginkgo, valerian root, or magnesium, so you discuss the lack of evidence of the efficacy of these
medications. Mr. Brown also raises the issue of a multivitamin with a daily dose of magnesium as an alternative to a specific supplement. You agree to this as part of the treatment plan.

In addition, Mr. Brown has heard about medications to prevent migraines. It is important to explain that prevention medication would not be the first step in treatment. Medications for migraine prevention would be used only if the plan did not work. In addition, migraine prophylaxis does not have FDA approval (Eiland, 2007; Gunner et al., 2008; Lewis, 2007a, b, c).

When do you want to see this patient back again?

Generally, you would want to see this patient back in a month. You would want to review the diary, discuss the effectiveness of the treatment plan, and support the family in the new treatment management. As the family develops self-care skills, these appointments can be spread further apart.

John and his father agree on the treatment plan. You give them written instructions that go over the key points of the treatment plan. Mr. Brown is able to show you the dosage of ibuprofen to give the child, and a measurer is dispensed by the pharmacy. John likes the idea of doing imagery to help control his headaches. Mr. Brown schedules the 1-month follow-up appointment before leaving the office.

On the follow-up visit in one month, the family brings the diary. They have identified that lack of fluid was a trigger for the first migraine during the previous month. They increased fluid intake before school and at lunch because the teacher felt she could not allow fluids in the classroom. Ibuprofen was more effective than Tylenol in relief of migraine pain, and imagery seemed to help John relax. Mr. Brown wants to come back in a month and continue the diary.

Key Points from the Case

1. The management of pediatric migraine requires family education, use of biobehavioral measures, medications for acute treatments, and if needed, daily preventive medications.

2. The treatment requires a stepwise approach. This involves determining how much of an impact the headache has on the child’s life, determining and then eliminating possible triggers, instituting a healthy lifestyle, teaching biobehavioral methods to control pain, and starting pain medication for acute headache early.

3. Offering treatment options and involving the family in the treatment decisions allows the patient and the family to practice self-care and manage the problem.

REFERENCES

Brna, P., & Doodley, J. (2006). Headache in the pediatric population.
Seminars in Pediatric Neurology, 13
, 222–230.

Eiland, L. S. (2007). Anticonvulsant use for prophylaxis of pediatric migraine.
Journal of Pediatric Healthcare, 21
, 392–395.

Guidetti, V., & Galli, F. (2004). Headache in children: diagnostic and therapeutic issues.
Seminars in Pain Medicine, 2
(2), 106–114.

Gunner, K. B., & Smith, H. D. (2007). Practice guidelines for diagnosis and management of migraine headaches in children and adolescents: part one.
Journal of Pediatric Healthcare, 21
, 327–332.

Gunner, K. B., Smith, H. D., & Ferguson, L. E. (2008). Practice guidelines for diagnosis and management of migraine headaches in children and adolescents: part two.
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, 52–59.

Headache Classification Subcommittee of the International Headache Society. (2004). The International Classification of Headache Disorders.
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Heng, K., & Wirrell, E. (2006). Sleep disturbance in children with migraine.
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, 761–766.

Isik, U., Ersu., R. H., Ay, P., Save, D., Arman, A. R., Karakoc, F., et al. (2007). Prevalence of headache and its association with sleep disorder in children.
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Lampl, C. (2002). Childhood-onset cluster headaches.
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Laurell, K., Larsson, B., & Eeg-Olofsson, O. (2004). Headache in schoolchildren: association with other pain, family history and psychosocial factors.
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, 150–158.

Lewis, D., Ashwal, S., Hershey, A., Hirtz, D., Yonker, M., & Silberstein, S. (2004). Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Society Standards Subcommittee and the Practice Committee of the Child Neurology Society.
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Lewis, D. W. (2007a). The epidemiology and treatment of pediatric migraine.
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(3), 65–74.

Lewis, D. W. (2007b). Headaches in children and adolescents.
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, 207–246.

Lewis, D. W. (2007c). Pediatric migraine.
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(2), 43–53.

Lisi, V., Garbo, G., Micchiche, F., Stecca, A., Terrazzino, S., Franzoi, M., et al. (2005). Genetic risk factors in primary paediatric versus adult headache: complexities and problematics.
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, 179–181.

Powers, S. D., & Andrasik, F. (2005). Biobehavioral treatment, disability, and psychological effect of pediatric headache.
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, 461–465.

Powers, S. W., Gilman, D. K., & Hershey, A. D. (2006). Headache and psychological functioning in children and adolescents.
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