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Is teenager's migraine down to exam stress?

Case history

Kerry's mother has brought her because she is suffering from recurrent 'sick headaches' and has to lie down in the school sickroom or stay home. She is worried that Kerry may have a brain tumour, and also wants a doctor's note in case she does badly in her GCSEs.

Should you see Kerry alone?

If you suspect that her headaches may be due to stress or emotional difficulties, and Kerry seems reluctant to discuss these areas, you could ask to speak to Kerry, and then her mother, alone. If she's under 16, check her capacity to consent; if either refuses, it's worth considering why. Kerry may ask you to keep some information secret; avoid giving an advance guarantee, as you may be told something that requires you to act.

Does Kerry have a brain tumour?

Probably not, but you need to take a full history and examine her thoroughly to reassure all three of you. Ask how long she has been getting headaches, what time of day they occur and what seems to bring them on or relieve them.

Are they related to her menstrual cycle or has she recently started the Pill (obtained elsewhere without her mother's knowledge)? Where is the pain, how long does it last, and how would she describe it? Are there any associated symptoms such as nausea, vomiting, visual or auditory disturbance, paraesthesiae or weakness? Which analgesics has she tried, over how long a period, and how many does she take?

What are her general health and lifestyle like? Is she sleeping normally, or feeling stressed or depressed? What about bullying, or problems at home or in other relationships? Migraine is probably the most likely cause; around 5 per cent of 15-year-old girls get them. But a brain tumour, tension headaches, and analgesic headaches are other possibilities at this age, and you need to exclude these, and other rarities. If you can make a good clinical diagnosis of migraine, you will also need to convince Kerry and her mother. If they or you have doubts, you may need to suggest a second opinion from a partner or specialist.

What is causing Kerry's migraines?

Is she on target for her expected GCSE grades or is she struggling to cope with the work? What pressure is she under from school and family, and is she devoting too much or too little time to her studies?

Is she working too late, or lying awake worrying? Too much or too little sleep, including teenagers' weekend lie-ins, may trigger migraines; getting up and going to bed at regular times may help. Relief of stress at weekends or during holidays can also trigger migraines.The timing and content of meals are also important.

Teenagers frequently eat irregularly or miss meals altogether, particularly breakfast; being thirsty or a low blood sugar can also trigger migraines. Some foods are well-known offenders, including caffeine, cheese, chocolate, pickled/dried foods and monosodium glutamate, plus others specific to individuals.

Migraine affects both sexes equally until puberty when it becomes more prevalent in girls. Migraines often occur just before a menstrual period as oestrogen levels fall, but migraines that get worse or start after commencing the Pill indicate increased risk of stroke and the OCP should usually be discontinued.

Other triggers include exercise, toothgrinding, neck problems, fluorescent lights, too much computer work, certain smells and changes in the weather. Kerry and her mother will probably welcome the idea that her migraines may be preventable, and be willing to keep a migraine diary detailing the circumstances of each attack. This should include the time and duration of any migraine, plus details of activities over the previous 48 hours. With luck, the diary may identify Kerry's triggers, so that she can avoid them.

What treatments can Kerry try?

Kerry has already discovered that lying down in a quiet, dark room often aborts a migraine. Depending on whether she can tolerate them, non-steroidal anti-inflammatory drugs, paracetamol or codeine may all work, but regular use can lead to rebound headaches (chronic daily headache or analgesic headaches).

She may also need an anti-emetic such as prochlorperazine (metoclopramide and domperidone may produce extra-pyramidal effects in this age group). Relaxation techniques, massage or acupuncture may be helpful.

Should you write a note for school?

You need to explain that there will be a charge as this is not an NHS service.

Only say what you can truthfully confirm. For example, you can say that you are treating Kerry for migraine and that it can strike suddenly; also that she would benefit from lying down in a darkened room and having access to medication (mention sedation as a side-effect if relevant). You can comment that migraines will prevent effective study when they occur, but you cannot vouch for the frequency or dates of her attacks, nor whether migraine has actually affected her GCSE performance.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Key points

  • Migraine often starts in puberty
  • Headaches often worry teenagers and parents; stress may be an underlying cause
  • Identifying and avoiding triggers by using a migraine diary is often worthwhile
  • Prophylactic therapy may be needed if migraines are frequent and severe
  • You must be able to justify anything you write in a private doctor's note

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