Case Learning Objectives
Morgan: 14-year-old Girl with Worsening Headaches
Broad Goals For This Case
- 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.
- Discuss the diagnosis of migraine based on Morgan's history and differentiate migraine from other headache types.
- Recognize "red flag" findings in Morgan's exam and historical details.
- Identify common migraine triggers and how they may be minimized.
- Describe both pharmacologic and non-pharmacologic strategies for migraine treatment that would be suitable for Morgan.
- Identify confounding headache factors and barriers to treatment (e.g., medication misuse or overuse, psychosocial stressors, environmental circumstances).
- Describe the anatomy and physiology associated with normal sensory transmission.
- Describe the pathophysiology associated with migraine.
- Describe how the physiology of migraine variants seen in children may differ from that of migraines seen in adults.
- Based on mechanisms of action, describe potential problems associated with combining the anti-histamines, cyproheptadine and diphenhydramine, to treat Morgan's migraine.
- Describe the mechanisms of action of other medications prescribed for Morgan, including ondansetron, rizatriptan, and amitriptyline.
- Discuss the consequences of Morgan's overuse of Excedrin Migraine (acetaminophen, aspirin, caffeine) based on their mechanisms of action.
- Describe the components of Migrelief and how they may contribute to alleviation of migraine symptoms.'
- Explain the important differences between the metabolism of medications in adolescents compared to adults.
- Describe factors affecting the use of digital technology by adolescents with migraines, including prevalence and availability.
- Describe the privacy issues related to use of web-based, wearable technologies, or apps for self-management of migraine.
- Explain the evidence supporting the use of step therapy and stopping rules for Botox insurance coverage.
- Identify at least one resource for new information about the value (relative cost and effectiveness) of migraine treatments.
Nursing (school nurse education)
- Accurately assess migraine symptoms in a student.
- Discuss a number of acute treatment options in the school setting, as outlined in a student's Headache Management Plan.
- Explain when a student with migraine symptoms can remain in school and when he/she needs to be sent home.
- List evidence-based medication therapy appropriate for the acute and prophylactic treatment of child/adolescent migraines.
- Assess a patient's ability to manage self-care, recommend an appropriate course of action based on described symptoms, and advise on need for professional medical advice if self-medication is inadequate.
- Describe how to counsel an adolescent about pharmacologic treatment for migraines in keeping with her level of health literacy.
- Identify signs and symptoms that indicate need for a referral to behavioral health.
- Explain how Morgan's avoidance may maintain her anxiety symptoms.
- Name one cognitive and one behavioral strategy from CBT used to treat Morgan.
- Define biofeedback and describe its administration.
- Describe how biofeedback might work to relieve Morgan's pain and/or stress.
- Explain changes in finger temperature induced by stress and relaxation.
Acupuncture Learning Objectives
- Describe the outcomes Morgan might expect from acupuncture in terms of mental health, pain and overall wellness.
- Briefly discuss the evidence for the suitability of acupuncture as an intervention for Morgan, the primary criteria for selecting interventions, and strategies for prioritizing these criteria.
- Describe a typical acupuncture assessment, including history, assessment, and physical exam.
- Describe the use of pattern diagnosis, channel theory and palpation.
- Describe how to find an acupuncture specialist, and write a referral, including rationale and typical duration of treatment.
Study Questions for the Adolescent Headache Case
- What are special considerations for treatment of an adolescent with this condition, compared to an adult?
- What lessons about self-medication does this case teach?
- What migraine triggers should be considered in creating a management plan?
- How can the patient collaborate in managing her headaches?
- How does the patient's anxiety affect her symptoms and relate to her treatment?
- Why is non-pharmcologic treatment recommended in addition to treatment with medications?