week 6 response 1

Case Scenario 2: Jim

Jim is a 17-year-old who was brought into the clinic today for a headache. He reports nausea and an increase in stress from school and after-school activities (basketball practice and debate team). His vital signs are within normal limits and his BMI is 24.

What more should you know about Jim?

Bickley et al. (2020) noted that the three most important attributes of headache are its severity, its temporal pattern, and its associated symptoms. Therefore, I’d like to know:

• The onset, location, duration, character, aggravating and relieving factors, severity, and time course of the headache.

• Age of onset: Progression of headaches over time and longest period of time without symptoms. Is the headache severe and of sudden onset? Does it intensify over several hours? Is it episodic? Or is it chronic or recurring? Steady or throbbing? Continuous or intermittent? Is there an aura? Is the headache “typical” or is there something different? Is there a recent change in its pattern? Does the headache recur at the same time every day? Location: Is the pain unilateral or bilateral? Garzon Maaks et al. (2020) noted that occipital or consistently localized headaches can indicate underlying pathology. Facial pain might be sinusitis. Oculomotor imbalance can produce a dull periorbital discomfort, whereas temporomandibular joint pain tends to localize around the periauricular or temporal areas.

• Character of the pain: sharp, throbbing, or pounding pain may indicate vascular migraine. Dull, constant pain may be tension-related or organic. Severity can be assessed by asking about limitations to activities and missed school days, although there are other factors that contribute to missed school and limited activities. How many “different kinds of headaches” are experienced?

• Exacerbating or alleviating factors; for example, does the headache get worse with coughing, sneezing, or sudden head movements, which can alter intracranial pressure dynamics? Triggers can include exercise, food or odors, and stress. Other triggers can include chocolate, processed meats, aged cheeses, nuts, changes in caffeine intake, dairy products, shellfish, and some dried fruits. Consistent findings, such as food triggers and a stable headache pattern with intervals of wellness over a long period, are reassuring and suggest a primary headache (Garzon Maaks et al., 2020). In most cases, a specific trigger or etiology is not ever identified. Children with recurrent, low-intensity headaches, no neurologic changes, and complete recovery between episodes are unlikely to have a serious intracranial etiology.

• What other symptoms, especially weakness or numbness in an arm or leg? Any associated symptoms such as double vision, visual changes, weakness, back pain,

otalgia, or loss of sensation. Is there fever, stiff neck, or a parameningeal focus like ear, sinus, or throat infection that may signal meningitis? Changes in gait, personality, vision, mentation, or behavior that do not occur concurrently with the headache are worrisome and warrant further evaluation and referral.

• Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness?

• Is there any overuse of analgesics, ergotamines, or triptans? Any substance use? • Family history: Some children with headaches, especially migraine, have a family

history of headaches. • Home management and medication dosages. • Did he have head trauma? • Psychological symptoms: He reports an increase in stress at school and after-school

activities. I would evaluate for concerns about family functioning. , bullying or peer issues at school, “over-programming” and family expectations, and meal, hydration, and sleep status.

What information in your history and exam would be red flags suggestive of secondary or pathologic headaches

According to Garzon Maaks et al. (2020), red flags suggestive of secondary or pathologic headaches are:

• Headache upon awakening from sleep that then fades; increases in frequency and severity over a period of only a few weeks; is persistent and unilateral

• First or worst headache • Pain that awakens the child from sleep • Vomiting but not nauseated that may relieve the headache, or intractable vomiting • Visual disturbances, diplopia, edema of the optic disc (papilledema) • Increased pain with straining, sneezing, coughing, defecation, or changes in position • Occipital region and neck pain • Educational, mental, personality, or behavioral alterations; irritability • New onset seizures or facial or extremity numbness • Unsteadiness or dramatic changes in balance, gait abnormalities • Fever with or without nuchal rigidity • Family history of neurologic disorders (e.g., brain tumors, neurofibromatosis, vascular

malformations) • Child has a history of a ventriculoperitoneal shunt, meningitis, hydrocephalus, tumor,

or prior history of a malignancy.

What education would you provide for Jim and his parents?

Garzon Maaks et al. (2020) suggested family and patient education is key to migraine and chronic headache management

• Develop step-by-step plan for rescue, complementary, and headache hygiene. This plan should include a piece for school management. Include ice, rest, and a dark environment.

• Keep a headache diary with triggers and the patient's progress. • Every person’s triggers are different, so identify and avoid them as much as possible.

Consider dietary, physiologic, and environmental possibilities. Common food triggers contain tyramine, nitrates, or MSG, such as aged cheese, artificial sweeteners, caffeine, chocolate, citrus fruit, cured meats, nuts, onions, and salty foods. Physiologic triggers include hormonal changes, emotional anxiety, irregular eating or sleep, and stress. Environmental triggers include such things as weather changes, altitude, lighting, sun and odors, motion or activity (too little or too much).

• Stress the importance of eating something for breakfast, even if just a healthy smoothie or power bar, three meals a day at regular hours, and not skipping meals. Every meal should contain a protein and be high fiber and low fat to keep sugar and sodium levels normal. Avoid foods that trigger headaches.

• Ensure intake of adequate hydration (4 to 8 glasses of water) to prevent dehydration- related headaches. Caffeine should be avoided. Sports drinks without caffeine may help during a headache.

• Try to have regular sleep (8 to 12 hours at night) and do not oversleep. Try to go to bed and wake up at about the same time every day. Turn off all electronic devices 1 to 2 hours before bedtime. Do not keep the phone in the bedroom.

• Aerobic activity 30 to 45″ with increased heart rate and 5 to 10″ of stretching most days. Weight lifting does not count.

• Develop a home-school headache plan to prevent excessive absenteeism. Coordinate with a school nurse to develop an intervention plan to soothe headaches when they occur; a quiet rest period may be allowed at school if needed, and the school nurse can help develop this plan. If the child remains home, activities should be restricted to bed, and all homework should be completed. The child should be returned to school if the pain improves during the school day. Minimize attention to the headache. Consider posture and lighting.

• Limit total use of devices requiring screen time. • Avoid overcrowded schedules and stressful situations. For Jim, maybe limit after-

school activities to one activity at a time, allowing time for homework and rest. The child and parents should be taught pain and stress management techniques, as well as relaxation exercises, including progressive muscle relaxation.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer Health. https://bookshelf.vitalsource.com/books/9781975109943

Garzon Maaks, D. L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., & Duderstadt, K. (2020). Burns’ pediatric primary care(7th ed.). Elsevier.