Quick Case: Teenager’s Migraines Stem from Surprising Source

Adolescent Medicine Program finds the key

Quick Case Study

The parents of an athletic 16-year-old girl decided to seek a new primary care physician for their daughter to address complex medical issues that she was beginning to face as an adolescent.

One of the girl’s most troublesome issues was debilitating migraine headaches, which interfered with her ability to participate in the competitive dancing that she loved. She had eliminated cane sugar and certain other foods from her diet, thinking those could be triggering the headaches, but they persisted.

Seeking a primary care physician who could more holistically address her many issues, the girl’s parents transferred her care to Charlene Wong, MD, a pediatrician in Duke’s Adolescent Medicine Program who has specialty training in adolescent and young adult health issues. The parents were also preparing to consult separately with a pediatric neurologist for diagnosis and treatment of her headaches.

“She presented with a host of complicated medical issues,” says Wong. “Fortunately, we have the luxury of longer teen visits and frequent follow-up, so we could pay extra attention to all of her needs and look closely at what could be causing her headaches.”

Question: What question was important for Wong to ask the patient in order to make a diagnosis?

Answer: Wong asked the patient about her menstrual cycles. The patient confided that she was having severe pain during her menses, and Wong suspected that there was a connection between the migraines and the dysmenorrhea. She prescribed the combined hormonal medications norgestimate and ethinyl estradiol, and within a few months, the girl began noticing a significant improvement in her menstrual pain and the frequency and severity of the migraines.

Wong advises physicians to ask teenagers directly about issues with their menstrual cycles because they could be related to many other physical or emotional complaints. “Painful, irregular, or heavy menses are very common, but it’s a taboo topic that patients often don’t bring up unless asked specifically —especially if a parent is still in the room,” she says. “Even though teenagers might not volunteer the information, menstrual issues are an important part of their overall health that we need to consider when caring for them.”

Wong was able to establish trust with the patient and give her an opportunity to discuss her issues in confidence over the course of several visits. “She had never been asked about her menses before,” says Wong, “but she knew the headaches were worse during that time and shared this important clue.”

The Adolescent Medicine Program is a hybrid between classic primary preventive care and specialty care, with a range of services that fall into four main categories: general primary care, reproductive health services, care for patients with complex medical conditions, and behavioral health care.

One unique feature of the program is that physicians spend more time with patients than is typical for a primary care office visit (30 minutes instead of 15). “Physicians are usually trying to cover so much in one short visit,” says Wong, “but our program gives us the ability to spend extra time with our patients—with their families and on their own—and to be more thorough in inquiring about physical, emotional, and social factors that have a huge impact on the health of young people.”

With Wong’s specialized care and the resources of the Adolescent Medicine Program, the hormonal medication was successful. The patient has made significant strides in managing both her menstrual and migraine issues as well as other issues that she had been struggling with. She’s enjoying dancing again, no longer has severe migraines or painful menses, and hasn’t needed to consult with a neurologist.