HEADACHEUKM FAMILY MEDICINE TELECONFERENCE 11TH FEB 2014BY DR NAZIHAH MOHD KHALIDSUPERVISOR: DR IRENE LOOI, CONSULTANT NEUROLOGIST HOSPITAL SEBERANG JAYA

GENERAL OBJECTIVE At the end of this session, the

postgraduate trainees in Family Medicine should be able to discuss the differential diagnosis of headache including providing appropriate treatment and advice to the patient.

SPECIFIC OBJECTIVES Formulate a differential diagnosis of

headache-either primary and secondary Recognize warning signs of symptomatic

(secondary) headaches Differentiate the common causes of

headache Understand the current theories about

the pathophysiology of migraine Initiate acute and long term treatment of

migraine

Introduction Headaches are one of the most common

neurological problems presented to primary care and neurologists.

They are painful and debilitating for individuals, an important cause of absence from work or school and a substantial burden on the society.

Epidemiology Almost everyone experience headache at some point

of their life Headache affects 95% of people in their life-time Headache affects 75% of any people in one year One in 10 people have migraine One in 30 people have headache more often than not,

for 6 months or more At least 90% of patients seen in neurology clinic with

headache will have migraine, tension type headache or chronic daily headache syndrome

Sinister cause of headache are rare, perhaps 0.1% of all headache in primary care

Classification Headache disorders are classified into primary and

secondary based on the International Classification of Headache Disorders, 2nd Edition (ICHD-2).

1. Primary headache Etiology not well understood. Classified according to their clinical pattern. Most common are tension type headache,

migraine and cluster headache. Medication overuse headache is common in those

taking medication for a primary headache disorder.

2. Secondary headache Organized by the underlying cause. Search for red flags, both in the history

and on general and neurologic examination.

Recommend confirmatory testing

Diagnosis The accurate diagnosis of headache

relies heavily on a careful history, supplemented by detailed general and neurological examinations.

Elements of the history and physical examination enable the clinician to diagnose primary headache disorders, and to elicit suspicion of secondary headache disorders (warning flags) that require prompt investigations.

Do not refer patients diagnosed with tension type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.

Include the following in the discussion with the patients:1. A positive diagnosis, including an explanation of the

diagnosis and reassurance that other pathology has been excluded

2. Options of management3. Recognition that headache is a valid medical disorder

that can have a significant impact on the person and their family or carers

Headache Diary Aid the diagnosis of primary headaches Record the following for a minimum of 8

weeks1. Frequency, duration and severity of

headaches2. Any associated symptoms3. All prescribed and over the counter

medications taken to relieve the headaches

4. Possible precipitants5. Relationship of headache to

menstruation

Consider further investigations or referral for patients who present with new onset of headache and any of the following:

1. Compromised immunity, for example, HIV or immunosuppresive drugs

2. Age under 20 years old and history of malignancy

3. A history of malignancy known to metastasize to the brain

4. Vomiting without other obvious cause

Migraine Migraine headache is one of the most common, yet

potentially debilitating disorders encountered in primary care.

Thorough history and physical examination can help confirm the diagnosis of migraine and rule out emergent condition.

Evidence based aid for migraine diagnosis POUND Pulsatile quality of headache One day duration (four to 72 hours) Unilateral location Nausea or vomiting Disabling intensity

Prodrome Affects 1 in 10 patients at most Usually 24-48 hours before headache E.g. mood change, behavioral change, yawning,

hunger, cravings, fatique (or the opposite) Aura Affects up to 30% Typically precedes the headache, evolving and

subsiding over 5-60 minutes There is often “no man’s land” period between

resolution of the aura and headache emergence, usually less than 60 minutes

Aura May sometimes intrude upon, or occur only

during the headache phase. Typically visual, although almost any

neurological symptoms may occur. The aura may occur in isolation, termed typical

aura without headache. Here focal epilepsy or transient ischaemic attacks (TIA) enter the differential. The length and evolution of attacks are helpful discriminators, focal seizures usually lasting seconds to minutes, TIAs do not evolve.

The nature of aura may change over

time and, when it does, it often alarms the patients. However this remains entirely consistent with migraine and does not indicate the need for urgent investigations.

People with aura who lose the associated headache as they get older, rarely complain; those who acquire aura in isolation, often in middle age, present typically to the TIA or eye clinic.

Migraine headache is typically severe, throbbing and

unilateral. Typically, it lasts for 24 hours or less but can continue for 72 hours, and occasionally longer (hours to days).

It often improves after vomiting and/or sleep, and generally improves with analgesia.

Associated features; most migraine patients complain of at least one of nausea/vomiting and dislike of noise/light/movement, and often all of these.

Patients with migraine feel (and look) unwell, and may complain of more global features such as mood change or lethargy. Rarely, more dramatic features including acute confusional states and even coma.

Frequency: median is about 1.5 attacks per month,

but at least 1 in 10 have weekly attacks. Triggers: hunger, sleep deprivation and “stress” are

all recognized, and certainly an assessment of the patient’s lifestyle is warranted.

Hormones: migraines during periods, migraine emerging in pregnancy or with exogenous estrogens are all well recognised. The difficulty is that the relationship is often inconsistent, with paradoxical effects. Patients who think that there is hormonal link must keep a daily dairy of headache and menstruation.

Migraine (management) Always assess whether any treatment at all is required-an

explanation and reassurance may be sufficient. Avoidance of triggering factors. Simple housekeeping tips such as not skipping meals,

adequate sleep etc and providing more information is often appreciated.

Explain that drug treatment is one avenue. Before starting/adding drugs, look at the patient’s current

medications and consider whether drug withdrawal is appropriate (e.g. COCP)

Explain how treatment should be used, symptomatic versus preventative treatment, so often confused by patients.

Symptomatic treatment is only effective for the headache/nausea elements; there is no symptomatic treatment for the aura.

Early nausea and vomiting are likely to reduce the absorption of oral medication, and the parenteral route might be better.

A stepped approach using simple analgesia first, is appropriate, as this is highly effective for many patients.

Preventive therapy may be appropriate for selected patients.

The US Headache Consortium’s recommended the following indications for preventive therapy:

1. Contraindications or intolerance to symptomatic therapy2. Headache symptoms occurring more than two days per

week3. Headache severely limit quality of life despite

symptomatic therapy4. Presence of uncommon migraine condition, including

hemiplegic migraine, basilar migraine, migraine with prolonged aura or migrainous infarction

Other treatments for migraine1. Acupuncture: the only alternative treatment

for migraine for which there is any evidence, it should be considered as a non-drug option, although limited availability.

2. Psychological intervention: no specific evidence to support its use, but a “pain management” approach may be helpful in patients with severe, drug resistant migraine provided medication overuse headache is kept in mind.

Tension Type Headache (TTH) TTH is an ill-defined and likely heterogeneous

syndrome. Diagnostic criteria are based on more on what it is

not rather than what it is. By definition, TTH involve pain that is NOT localized,

NOT throbbing, NOT aggravated by activity and NOT severe, associated neurologic, autonomic or migrainous features are NOT components of TTH.

NO significant nausea, NO vomiting, photophobia and phonophobia CANNOT both be present.

Finally, must exclude secondary causes of headache possibilities.

Most episodes develop during waking hours and progression over the course of the day is common.

The most frequently reported triggers for TTH are mental or physical stressors, which explains why the term “tension-type” headache. Used to be known as “stress” and “muscle contraction” headache.

Other commonly described triggers are hunger, dehydration, overexertion, alterations in sleep patterns, caffeine withdrawal and female hormonal fluctuations.

It is crucial to elicit the temporal pattern of the headache disorder during clinical assessment because the extensive symptoms overlap between primary and secondary headaches.

General and neurological examinations are key component to clinical evaluation and can provide clues to the potential presence of organic disease.

The difficulty in distinguishing ETTH from migraine headache, two of the most common episodic headache types, is widely acknowledged.

Slight female preponderance; female to male ratio 5:4

Most develop prior to age 30, with peak prevalence between the ages of 40 and 49 and a subsequent decrease with age in both sexes.

There is also a correlation between prevalence of ETTH and higher educational level.

Link exists between TTH and emotional distress of life tension. Environmental influences appear to carry greater importance than genetic factors in the development of TTH.

Although attacks of TTH are generally less disabling than those of migraine, work absence are common, and the total societal burden appears to exceed that of migraine because of the high prevalence of TTH.

TTH (Management) Approach of management involves a

combination of lifestyle, physical and pharmacologic measures.

Nonpharmacologic management should always be considered, although the scientific evidence is limited.

Recommendations for regulation of sleep, meals, and exercise are generally quite valuable.

Stress management and behavioral therapies are useful in the management of TTH

TTH is mainly managed through administration of medication during acute episodes.

Simple analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and combination agents are most commonly recommended.

Their use should be strictly limited to an average of 2 to 3 days per week to avoid medication overuse headache and potential contribution toward transformation into CTTH.

NSAIDs are generally considered the drugs of choice for acute TTH.

Ibuprofen and naproxen sodium are listed as first line agents in the NSAIDs category because of the better gastrointestinal tolerability.

Opioid analgesics are not recommended for the management of TTH.

Preventive pharmacologic therapy is generally advised for those patients experiencing at least 2 to 3 headache days each week.

Although analgesic may be continue to be beneficial when taken at such levels, the issues of medication overuse headache and transformation into more refractory cases of CTTH must be considered.

Indications for the institution of daily pharmacologic preventive therapy:

1. Progression in frequency or severity of attacks

2. Development of adverse events with acute medications

3. Decline in efficacy of acute medications These medications should be started at

low doses and gradually increased based on efficacy and tolerability

Once an effective dose is reached, treatment is typically continued for 6 to 12 months, at which point daily medication may be tapered and the patient followed clinically.

The prognosis of TTH is generally favorable, with limited disability during headache occurrences and age related improvement or resolution of episodes later in life.

Cluster headache Cluster headache is a primary headache

disorder classified with similar conditions known as trigeminal autonomic cephalalgias.

Typified by recurrent attacks of unilateral pain, which are very severe and usually involve the orbital or periorbital region innervated by the first (ophthalmic) division of the trigeminal nerve.

Characteristic signs and symptoms of activation of the cranial autonomic pathways accompany the pain on the same side.

This condition has a heritable tendency in some families and first degree relatives of affected people have an estimated 14-48 fold increased risk of developing it.

Male to female ratio varies between 2.5:1 and 3.5:1

Patients typically start to develop the attack in their third to fifth decade.

The pain of cluster headache is unilateral(97%) of patients with episodic disease and mainly focused behind the eye (88-92%), over the temple (69-70%) or over the maxilla (50-53%).

Patients describe the pain as a sharp, piercing, burning or pulsating sensation like “having a red hot poker forced through my eye” and they reported that the intensity is so extreme it is unlike anything they have ever experienced (11 out of 10).

The attacks should last between 15 and 180 minutes, although on rare occasions they can last longer.

The onset is rapid and the sensation increases from serious discomfort to excruciating pain over the course of a few minutes.

The pain usually stays at maximal intensity for the duration of attack, although it may wax and wane slightly, or be punctuated by super intense stabs of pain.

The attack will often end as abruptly as it started.

Between 70% to 93% of patients describe a sense of restlessness and agitation during an attack and will often pace, rock back and forth, and bang their heads.

Cluster headache (management) The mainstay of abortive treatment

consists of inhaled oxygen and parenteral triptans.

Standard analgesia is ineffective and there is no evidence to support the use of NSAIDs, paracetamol, codeine or opioids in the treatment of individuals attack.

Oxygen: patients should continuously inhale 100% oxygen at 12L/min for at least 15 minutes through a non-rebreathing facemask

Triptans: parenteral triptans have been shown to be an effective treatment for individual attacks, whereas orally administered triptans are not.

Preventive treatment Aims to suppress the attacks for the

duration of the bout, or over longer periods in those with chronic cluster headache, with the fewer possible side effects.

The preventive drug of choice is verapamil. Baseline ECG should be done before starting

verapamil, and should be repeated 10 days after the dose change and reviewed before each dose increased, paying particular attention to the PR interval.

This is essential because relatively high incidence of heart block associated with verapamil.

Other side effects of verapamil are constipation, dizziness and peripheral oedema.

Verapamil can be slowly withdrawn and stopped once the bout is assumed to have ended and lower doses do not allow breakthrough attacks.

The maximum efficacious dose achieved can then be given at the beginning of the subsequent bouts, as long as baseline ECG remains within normal limits.

Other agents such as lithium, topiramate, sodium valproate, pizotifen and gabapentin are occasionally used with some success, although data from clinical trials are limited.

Medication overuse headache (MOH)

The International Classification of Headache Disorders, 2nd Edition states that for a diagnosis of MOH, all of the following criteria must be present:

1. Headache occurring on 15 or more days per month2. Regular overuse for more than 3 months of one or

more acute/symptomatic treatment drugs on 10 or more days per month; or simple analgesics alone or any combination of ergotamine, triptans and opioids on 15 or more days per month

3. Development or marked worsening of headache during medication overuse

MOH occurs only in patients with a history of primary headache.

It is most likely to affect patients with migraine and/or tension type headache.

MOH most prevalent in those aged 40-50 years and affects about three times more women than men.

Prevalence of MOH: General population:1% adults 0.5% adolescents

(aged 13-18 years) 25-64% in those attending tertiary care 90% in patients with chronic daily headache

It is the frequency of doses rather than the absolute quantity of drug consumed that is important; lower daily doses carry a greater risk of causing MOH than larger weekly doses.

MOH is often present and at its worst on waking in the morning.

Patients with MOH develop tolerance and withdrawal symptoms which are similar to signs of dependence on drugs traditionally classified as addictive.

Diagnosis: patient’s history and clinical presentation.

History: 1. use of analgesics (including for reasons

other than headache)2. use of over-the-counter and prescribed

medications3. acute medications becoming less

effective4. escalation to using more drugs

Investigations are generally not required to diagnose MOH.

Assessment should also search for possible complications of regular drug intake (e.g. recurrent gastric ulcers, anaemia).

MOH (management) The objectives in managing patients with

MOH are:1. Reduce the frequency and/or severity of

headache2. Reduce consumption of acute

medication (and possibly dietary caffeine)

3. Improve responsiveness to acute and preventive medications

4. Alleviate disability and improve quality of life

These are addressed by the following means:

1. Stopping the overused medications2. Managing withdrawal symptoms 3. Reviewing and reassessing the

underlying primary headache disorder4. Preventing relapse

British Associations for the Study of Headache state that patients with MOH fare better if they are motivated and understand that their “treatment” is likely to be causing their frequent headache.

They should be forewarned that withdrawal initially aggravates symptoms.

Withdrawal should be planned in advance to avoid unnecessary lifestyle disruption, and done under the supervision of a doctor or headache specialist nurse.

It may be necessary to arrange absence from work for 1-2 weeks.

The guidelines also recommend a diary to record symptoms and medication use during withdrawal, and good hydration should be maintained.

Most drugs causing MOH can be stopped abruptly. The Scottish Intercollegiate Guideline Network

suggests that opioids and benzodiazepines should be withdrawn gradually.

Gradual reduction in caffeine intake may be preferable to abrupt withdrawal.

The withdrawal headache and associated symptoms varies depending on the types of medications that have been overused.

Overall improvement occurs within 7-10 days when the causative drug is a triptans; after 2-3 weeks when it is simple analgesics; and after 2-4 weeks when it is an opioid.

The mean success rate for withdrawal therapy (defined as at least a 50% reduction in headache days) over 1-6 months is around 72%.

Factors that affect the likelihood of successful withdrawal include:1. The duration of regular drug intake (a longer duration is

associated with a worse prognosis)2. The specific drug overused (e.g. withdrawal from triptans has a

better prognosis than other drugs)3. The underlying headache type (e.g. TTH plus combined TTH and

migraine have higher risk of relapse than other types)4. Low self reported sleep quality (associated with worse prognosis)5. High self reported bodily pain (associated with worse prognosis)

Managing withdrawal symptoms Treatment of vomiting: antiemetic

(metoclopramide, domperidone) Use of NSAIDs: naproxen (250mg TDS or

500mg BD for 3-4 weeks then stopped or taken for 6 weeks-TDS for 2weeks,then BD for 2 weeks, then OD for 2 weeks)

Corticosteroids: studies shown mixed results

Triptans

Addressing the primary headache Symptomatic relief (if needed) may be

reintroduced for symptomatic relief after 2 months, with explicit restriction to ensure that the frequency of use does not exceeds 2 days per week on a regular basis.

For those on prophylaxis medication, the efficacy may return after successful withdrawal of the overused medication.

Preventing relapse of MOH Defined as frequent use of any acute headache medication

on more than 15 days per month for at least 3 months after recovery from previous MOH.

Most relapses occur within the first year after withdrawal. Risk factors for relapse:1. TTH or migraine plus TTH, rather than migraine alone2. Longer duration of migraine with more than 8 headache

days per month3. Lower improvement after drug withdrawal 4. Greater number of previous preventive treatments tried5. Male gender6. Intake of combined analgesic drugs

How to prevent relapse:1. Monitor regularly2. Combination drugs should be avoided3. May require extended support (social)4. Primary headache must be treated using different

approach other than medications-massage, acupuncture, behavioral therapies.

Patients with MOH should be referred to neurologist if attempted withdrawal fails in primary care. Patients who have psychiatric comorbid or drug dependence behavior should have these conditions treated additionally.

Secondary headachesICHD-11 defined secondary headaches as follows: Headache attributed to head and neck trauma Headache attributed to cranial or cervical vascular

disorder Headache attributed to nonvascular intracranial disorder Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disturbance of homeostasis Headache attributed to psychiatric disorder Headache or facial pain attributed to disorder of

cranium, neck, eyes, ears, nose, sinus, teeth or other facial or cranial structures

During history, symptoms suggestive of secondary cause should become obvious.

Red flags should be elicited and ensure the following have been covered:

1. Other neurological symptoms: unless part of typical migraine aura or autonomic features, these should always suggest a secondary cause

2. Systemic features: weight loss, fever, and other systemic features should stimulate concern. Patients with benign headache are not persistently unwell.

The key issue is how the headache evolved. One which reaches its maximum intensity

immediately or within minutes always suggests subarachnoid haemorrhage (SAH), even though only about 10-25%of such patients will prove to have this.

Unfortunately, there are no accurate discriminators in the history, and although other neurological symptoms, neck stiffness, vomiting, seizures or transient disturbances of consciousness, all indicate an increased likelihood of SAH, their absence does not exclude it.

Other important secondary causes of abrupt onset headache include:

1. Ischaemic stroke, especially due to arterial dissection

2. Intracerebral haemorrhage, sometimes with no localising signs

3. Intracranial venous thrombosis4. Intermittent hydrocephalus5. Meningoencephalitis

Evaluation of patients with headache and any of the following features, and consider for further investigations and/or referral:

1. Worsening headache with fever2. Sudden onset headache reaching maximum intensity

within 5 minutes3. New onset neurological deficit4. New onset cognitive dysfunction5. Change in personality6. Impaired level of consciousness7. Recent (typically within the past 3 months) head

trauma

8. Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze

9. Headache triggered by exercise10. Orthostatic headache (headache that changes with

posture)11. Symptoms suggestive of Giant Cell Arteritis (also known

as temporal arteritis, characterised by the inflammation of the walls of medium and large arteries. Branches of the carotid artery and the opthalmic artery are preferentially involved, giving rise to symptoms of headache, visual disturbances and jaw claudication)

12. A substantial change in the characteristics of their headache

13. Symptoms and signs of acute narrow angle glaucoma (an uncommon eye condition that results from blockage of the drainage of fluids from the eye. Symptoms of acute glaucoma may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of semi dilated pupil compared with the presence of a constricted pupil in cluster headache)

Depression: headache is not uncommon symptom of depression, although there may also be overlap with other disorder as well.

Paediatric Headache Headaches are common during

childhood and become more common and more frequent during adolescence

The environment of a child’s world includes school, home, and community

All of these areas have profound influences on headache

Epidemiology The prevalence of headache ranged from

37% to 51% in those who were at least 7 years of age and gradually rose to 57% to 82% by age 15

Before puberty, boys are affected more frequently than girls, but after the onset of puberty, headaches occur more frequently in girls

Classifications Rothner-a more practical approach to

paediatric headache He classifies into 4 patterns that are

easily distinguishable from each other Location of pain and duration is not very

important

Evaluation Medical evaluation requires a thorough

history followed by a complete physical and neurological examination

A detailed neurologic examination is essential

More than 98% of children with brain tumors have objective neurological findings

CT or MRI is indicated in some patients with acute headache, chronic progressive headache pattern and focality on neurological examination

Migraine (paeds) Migraine with or

without aura is the most common form of acute recurrent headache in children

Migraine (treatment) Divided into 2 phases:1. General measures

-confidently reassure patient and caregivers-identify and removing headache triggers (disrupted sleep, skipped meals, stress), regulating lifestyle and instituting behavioral therapies (relaxation techniques, stress management)-caffeine-abuse or withdrawal can precipitate headache in adolescents

2. Pharmacologic management -intermittent use of analgesics-successful use of analgesics includes:1)taking enough medication2)taking medication early in the course of the headache3)making medication available to the child (especially at school)

Conclusions Most headache are due to a primary headache

syndrome A detailed clinical history and complete general

and neurological examinations, with special attention to the red and yellow flags, are fundamental to this process.

Patients want an adequate hearing of their symptoms, followed by a diagnosis and understandable explanation.

Most patients need reassurance, some will benefit from treatment and few require investigations.

Some headache syndromes are amenable to medical treatment (e.g. migraine) but others are much less so (chronic daily headache) and an honest explanation is usually appreciated.

Above all, patients want someone who is interested in their headache and who will listen to their story.

Case scenario 1 Aini, a 25-year old single lady complains

of headache, intermittently for 3 months duration. The headache is progressively worse since a month ago whereby she will experience it almost every day. She describes the headache as tight band in nature and frequently happens at work. There is no aura or other symptoms noted.

How would you manage her?

Case scenario 2 A 32 year old man comes to your clinic complaining of headaches. He

began having headaches about two months ago. They usually occur at the end of the day, seem to start at the back of his head, and are of a throbbing nature. They occasionally radiate out onto the tops of his shoulders, or up over the top of his head. Ibuprofen usually, but not always, relieves his pain. He has history of childhood asthma, and aside from ibuprofen PRN for the headaches, he takes no other medications. He has recently gotten a promotion at work, and is working 12 hours a day 6 or 7 days a week, and hasn’t been to the gym in a month.

The patient states that his 37 y/o first cousin suddenly started having headaches last year and was found to have a brain tumor. The patient demands that you give him a referral for an MRI.

Is neuroimaging appropriate in this patient? What are the indications for imaging in patients with headache? What is the most appropriate radiologic screening test in patients with

new onset headache?

Case scenario 3 Lesley is a 35 year old woman with a 10-year history of migraines. The frequency of

her migraines has increased from one to two–three per month, and they seem to be triggered by sleep deprivation and stress. The migraines include visual auras which precede the headache. Lesley has two children aged 2 and 4 years and no other relevant medical history.

Lesley presents to her GP with a 24 hour history of unilateral severe throbbing headache which is associated with photophobia, nausea and vomiting (three times in 24 hours). As discussed previously with her GP, Lesley’s initial self-management is naproxen 275mg and metoclopramide 10 mg orally with a repeated dose of naproxen 275mg every four hours. Lesley has had no symptom relief from the naproxen. Lesley has been unable to attend work or care for her children and states that she rarely has such a severe attack.

On examination Lesley looks pale and tired. Blood pressure is 120/75 mmHg, heart rate regular at 70 beats per minute and her Glasgow Coma Scale is 15/15. Apart from the photophobia she has no other obvious neurological signs or symptoms and the remainder of her other physical examination is normal.

How would you manage Lesley’s condition? If Lesley requests for treatment to reduce the frequency of her headaches, what

would you prescribe and why?

Case scenario 4 Joseph is a 14-year-old boy. He attends your clinic accompanied by

his mum, Claire. He presents with a 2-month history of headaches that he describes as “banging” and that make his head “very very painful”. He says that in the past 2 months he has had 6 of these headaches. He also says that light hurts his eyes when he has the headaches. He does not feel nauseous or vomit during the headaches. Claire tells you that when Joseph has the headaches he is unable to go to school and that the headaches last from 2 to 4 hours. She gives Joseph paracetamol and if that doesn’t work she also gives him ibuprofen. Joseph reports that this combination of medication helps but that it still hurts a lot until the headache eventually goes completely.

Joseph and Claire ask if Joseph’s headaches are migraines Is anything more he can take to ease the pain and reduce the

amount of time he is taking off school? How would you manage Joseph as compared to Lesley?