The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
It is not uncommon for adolescents with chronic pain conditions to be absent from school for long periods of time. In many cases, families may seek out a home-schooling program, or a modified school schedule in which the child is in school for limited hours during the day. This decision-making process is often complex and difficult, and in many cases, parents/guardians will ask for the physician’s input. Herein, the authors present a sample case in which an adolescent presents with refractory chronic migraine and comorbidities.
Hypothetical Case
Emily is 15 years old, with a history of moderate to severe daily migraine since age 13. With her daily headaches, Emily experiences severe photophobia and mild sonophobia. She also suffers from moderate generalized anxiety, dysthymia, moderate insomnia, and irritable bowel syndrome, with reflux and constipation. In the past year, she has missed many days of school.
Emily has been to multiple physicians and trialed multiple preventive medications, but her migraine symptoms have failed to improve. Onabotulinum toxin A (Botox) has improved her headaches to a small degree and abortives help, but only relieve 30% of the pain.
She struggles in school due to the bright lights and noises, which exacerbate her pain, and has difficulty functioning before 11 am. Physical therapy has not been successful. In conjunction with her family and her psychotherapist, she has decided to consider homebound education.
Discussion
Much like adults, each child’s experience with chronic headache or chronic migraine is unique. Variables may include: frequency and severity of headaches; response to medication (including family history response); psychological makeup; history of abuse; stress levels and responses to stress; family/home dynamics; catastrophizing; coping ability; and available support systems.
For the adolescent with chronic headache, function is often significantly better at home as they do not have to contend with a stressful, noisy, bright environment throughout the day. In looking at the larger adolescent patient base, it is important to consider the following when providing clinical advice regarding a homebound program. Chronic headache/migraine is used as an example.
Frequency and Severity of Symptoms
The nature of the adolescent patient’s headaches is important as New Onset Daily Persistent Headache (NDPH) is often more difficult to treat, and more likely to lead to a homebound situation than transformed migraine or episodic migraine. Family history may provide clues. If headaches are prevalent on both sides of the family, for instance, then it is more likely that frequent or daily headaches will occur in the child.
Medication Options
When preventive medications are effective at treating chronic headache, daily functioning is usually improved. For those who experience frequent or daily migraine, however, preventives may not be effective in the long-term. Preventives tend to work reasonably well for 3 to 6 months, but the dropout rate from 6 to 12 months is significant. Side effects may also limit use.
In the authors’ clinical experience, Botox is most helpful if abortive medications are also effective. At the same time, a headache patient, especially a young one, cannot feasibly “chase” the pain all day, every day. Thus, medication selection must be highly individualized.
Rather than using traditional algorithms, the authors have found that assessing previous response and side effects to medications, along with a family history of medication response, are most helpful. For instance, if a mother brings in her daughter, and the clinician suggests topiramate, and the mother says, “Yes, topiramate was a miracle for me!” we then know that topiramate may be a reasonable medication for the daughter. Not only may the genetic response to medications be similar but in this case, a “placebo by proxy” factor may come into play.
Weight and energy level also play a role in determining medication choice. Fatigue is often present in patients who experience daily headaches; thus, medications that exacerbate drowsiness should be avoided.
Medical comorbidities in adolescents with chronic headache or migraine may range from gastrointestinal issues and low blood pressure to tachycardia, asthma, and more. These, along with any psychiatric comorbidities (see below), should be factored into medication choices. For anxiety and depression, in particular, serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine or venlafaxine, may help to manage both headaches and moods (assuming mild bipolar is not present).
Insomnia is also commonly encountered in the adolescent population and the older tricyclics may be helpful in these cases. Certain muscle relaxants may improve insomnia as well as pain. Selective serotonin reuptake inhibitors (SSRIs) may help with moods, but usually are ineffective for headache prevention.
Finally, cost may be an issue with certain medications. For instance, Botox is indicated for those age 18 and older. Many adolescents receive Botox off-label to treat chronic migraine, but it is costly as a result. Thus, patient preference should be addressed.
Psychological Conditions
Anxiety and/or depression are commonly seen in homebound adolescents with chronic headache. In the authors’ experience, referred psychotherapy is very beneficial to the chronic headache or chronic migraine patient in order to explore any related stresses and family dynamics. For adolescents with significant depression, the mild end of the bipolar spectrum may also be considered. (It is important not to prescribe antidepressants prior to assessing for the soft signs of bipolar disorder, which can be easily overlooked.)
The adolescent’s family history, including any present mental health conditions or substance use disorders, is particularly important as the home environment may lead to increased levels of anxiety and depression.
