Case Learning Objectives

Morgan: 14-year-old Girl with Worsening Headaches

Broad Goals For This Case

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

Specific Objectives:


  1. Discuss the diagnosis of migraine based on Morgan's history and differentiate migraine from other headache types.
  2. Recognize "red flag" findings in Morgan's exam and historical details.
  3. Identify common migraine triggers and how they may be minimized.
  4. Describe both pharmacologic and non-pharmacologic strategies for migraine treatment that would be suitable for Morgan.
  5. Identify confounding headache factors and barriers to treatment (e.g., medication misuse or overuse, psychosocial stressors, environmental circumstances).

Pain Pathways

  1. Describe the anatomy and physiology associated with normal sensory transmission.
  2. Describe the pathophysiology associated with migraine.
  3. Describe how the physiology of migraine variants seen in children may differ from that of migraines seen in adults.


  1. Based on mechanisms of action, describe potential problems associated with combining the anti-histamines, cyproheptadine and diphenhydramine, to treat Morgan's migraine.
  2. Describe the mechanisms of action of other medications prescribed for Morgan, including ondansetron, rizatriptan, and amitriptyline.
  3. Discuss the consequences of Morgan's overuse of Excedrin Migraine (acetaminophen, aspirin, caffeine) based on their mechanisms of action.
  4. Describe the components of Migrelief and how they may contribute to alleviation of migraine symptoms.'
  5. Explain the important differences between the metabolism of medications in adolescents compared to adults.

Population Health

  1. Describe factors affecting the use of digital technology by adolescents with migraines, including prevalence and availability.
  2. Describe the privacy issues related to use of web-based, wearable technologies, or apps for self-management of migraine.
  3. Explain the evidence supporting the use of step therapy and stopping rules for Botox insurance coverage.
  4. Identify at least one resource for new information about the value (relative cost and effectiveness) of migraine treatments.

Nursing (school nurse education)

  1. Accurately assess migraine symptoms in a student.
  2. Discuss a number of acute treatment options in the school setting, as outlined in a student's Headache Management Plan.
  3. Explain when a student with migraine symptoms can remain in school and when he/she needs to be sent home.


  1. List evidence-based medication therapy appropriate for the acute and prophylactic treatment of child/adolescent migraines.
  2. 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.
  3. Describe how to counsel an adolescent about pharmacologic treatment for migraines in keeping with her level of health literacy.

Behavioral Health

  1. Identify signs and symptoms that indicate need for a referral to behavioral health.
  2. Explain how Morgan's avoidance may maintain her anxiety symptoms.
  3. Name one cognitive and one behavioral strategy from CBT used to treat Morgan.


  1. Define biofeedback and describe its administration.
  2. Describe how biofeedback might work to relieve Morgan's pain and/or stress.
  3. Explain changes in finger temperature induced by stress and relaxation.

Acupuncture Learning Objectives

  1. Describe the outcomes Morgan might expect from acupuncture in terms of mental health, pain and overall wellness.
  2. 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.
  3. Describe a typical acupuncture assessment, including history, assessment, and physical exam.
  4. Describe the use of pattern diagnosis, channel theory and palpation.
  5. 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

  1. What are special considerations for treatment of an adolescent with this condition, compared to an adult?
  2. What lessons about self-medication does this case teach?
  3. What migraine triggers should be considered in creating a management plan?
  4. How can the patient collaborate in managing her headaches?
  5. How does the patient's anxiety affect her symptoms and relate to her treatment?
  6. Why is non-pharmcologic treatment recommended in addition to treatment with medications?