Adolescence & Headache

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by Robert L. Hamel, PA-C., MHNI, Ann Arbor, Michigan

 

Adolescence is a difficult time. Adolescents experience multiple biological, social, psychological, and educational changes simultaneously. The addition of illness to this complex developmental process can be a small burden, or have a large impact, depending on individual circumstances. When the illness is head pain, pain management becomes dependent on a therapeutic alliance between the patient, parents, and healthcare professionals.

Who?

As boys get older, they tend to experience less migraine, a common type of adolescent headache. Perhaps due to the effects of estrogen, girls tend to experience more migraine.

Assessment

The history is the most important aspect of assessment. It is important to know whether a headache began suddenly and persisted, is intermittent associated with menstrual cycles, or has no apparent pattern. Headaches can evolve from intermittent to daily or become daily suddenly after a viral infection or injury. Distinguishing characteristics can emerge during this portion of the assessment which help to direct therapy.

Any change in headache based on position of the body is important to note. Anatomical and fluid dynamic contributing factors to headache may be investigated based on a history of a positional headache.

Other details that are important include the location of the headache, the character of the pain, associated symptoms (nausea, vomiting, light sensitivity, sound sensitivity, etc.), what makes the pain worse, or what makes the pain better. In addition, pain does not occur in isolation. It is important to evaluate for mood as depression and anxiety may become aggravating influences if present before the pain, or may emerge as a result of the pain. Understanding the family's situation, i.e., divorce, separation, beginning a new school, and other socio-economic factors, may be important in assessing any developing impairment associated with head pain.

Unfortunately, some adolescents do use illicit substances. Specific questions directed at obtaining this information cannot be overlooked. This includes the use of tobacco and alcohol.

Relationships with peers in school may change as children become adolescents. Cruelty is common in school. School absence due to headache can become school avoidance if a child is "different," does not fit in, or is otherwise having difficulty progressing through a school culture. This can become a difficult problem to assess and requires the understanding and cooperation of professionals and parents with the goal of treating the head pain, but also expecting as much function as possible out of the individual adolescent.

Family medical history may shed light on parents' or grandparents' headaches or other pain disorders.

Physical examination is often normal in adolescents with headache. Indeed, the adolescent may appear to be not in pain at all, but reporting severe pain. This may be especially true of patients reporting daily pain. It is relatively easy to tell the difference between a girl with migraine headaches associated with menstrual cycles who is otherwise normal every other day of the month, versus a 16-year-old who reports a severe daily headache. Both patients must be acknowledged as reporting what they feel. But in the case of the daily headache, a much more thorough investigation of all circumstances, medical, social, familial, and education, would likely be important.

Physical examination should focus on areas of tenderness, neurological function, vital signs, and areas of sensitivity to light touch.

In the case of daily headache is may be necessary to pursue a detailed laboratory investigation including cerebrospinal fluid analysis obtained after a lumbar puncture, MR imaging of the brain and possibly the neck, and other laboratory tests.

Treatment

Treatment should be individualized. It may be as simple as providing a migraine abortive once or twice a month, or as complicated as providing medicine, psychological therapy, and interacting with school representatives and parents, and monthly medical visits.

Adolescents may be more responsive to cognitive behavioral techniques such as hypnosis, biofeedback, and relaxation techniques. Oral routes of medication are preferable to injectable or suppository use, whenever possible. Reliance on opioid medications should be avoided and early intervention by an experienced multidisciplinary pain management team whenever daily headache and significant school absence coexist is best.

In conclusion, adolescent headache can be a simple or extremely complicated problem, which, in either case, should be taken seriously by parents and medical professionals, as well as the adolescents themselves. Head pain is a condition that may evolve over time from intermittent to chronic, and early treatment to prevent rebound headache and even disability status as an adult are good reasons for early intervention. Education becomes the focus of treatment in adolescents as migraine and other primary headache disorders are not susceptible to cure and often require a lifetime of treatment strategy.

 

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The opioids (narcotics) cause progression of the illness (Chronic Daily Headache), not termination, and will actually make the individual much worse over time. It is easier and quicker to give the patient a pain killer than to "get into the trench" and try solve the problem. Patients with chronic daily headache require time, diligence, and frequent access from their physician.

Interview: Dr. Joel Saper, MHNI
-from the book Chronic Daily Headache

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The book Chronic Daily Headache features
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