Learning Objectives

Describe the diagnostic features of migraine in adolescent patients.
Discuss the pathophysiology of migraine headaches in adolescents and relate to the present case.
Discuss both pharmacologic and non-pharmacologic treatment strategies for migraine in an adolescent, using an integrative medicine approach.
Discuss psychosocial, environmental, and lifestyle factors that may trigger or complicate treatment of migraine headaches.
Demonstrate how to encourage active self-management in concert with ongoing provider care.

Morgan is a ninth grader in a new school who has been suffering from more frequent (2/3 days/wk) and more severe headaches in the past 6 months. She has been visiting the school nurse's office frequently with severe headaches and the nurse has been sending her home. She is anxious about missing school, sports activities, and social events because of her headaches.
Morgan experienced cyclic vomiting when she was 5-7 years old. Six months ago, just before her headaches began to worsen, she suffered a concussion in a volleyball game. She is also feeling anxiety about being in a new school with many ongoing activities in softball, volleyball, music and drama, in addition to her school work, and she worries that the headaches are going to seriously disrupt these activities. She sleeps 6 hours per night and has frequent stomach aches.
Her mother has been giving her Excedrin Migraine, which she takes daily (1-2 doses). Occasionally, she has used her mother's Tylenol with codeine. She also drinks tea, and has energy drinks to "provide vitamins."
She complains of unilateral, right-sided temporal throbbing pain with sharp pain and feeling of fullness behind right eye. She reports feeling irritable the day prior to migraine onset. Headaches are preceded by tingling sensation in her fingers and at times, and she has trouble "getting the words out." Headaches are often associated with her menstrual periods.
Her PCP refers her to a neurologist, who diagnoses her with migraine headaches, likely exacerbated by medication overuse and anxiety. Her anxiety may well be increased by her mother's concern about her headaches.
Recommended treatment includes discontinuation of OTCs, and taking Amitriptyline and Migrelief, in addition to rizatriptan (Maxalt) at onset of a headache. She is advised to eliminate caffeine use, eat breakfast without fail and then small meals throughout the day, maintain a routine schedule of sleeping, and avoid overscheduling. The school nurse is educated to help Morgan manage her attacks without going home from school, using preventive medication and rest.
She is referred to a psychologist for anxiety reduction and relaxation therapy. Other possible interventions that she might try are acupuncture, biofeedback, or other alternative therapies.