Anxiety in a Headache Patient: Case Challenge
History: Caitlin is a 27-year-old woman with a history of migraines and anxiety. She began having separation anxiety at age 5. The patient can remember hanging onto her mother’s leg “for dear life” on the first day of kindergarten. Later, at 9 years of age, symptoms of obsessive-compulsive disorder (OCD) began; these included intrusive thoughts, an aversion to germs, and the compulsion to touch everything “equally on both sides.” These symptoms waxed and waned over time. By age 15, Caitlin suffered from generalized anxiety disorder (GAD), with intense worrying and feeling “keyed up.” The anxiety would, at times, trigger a migraine. Additionally, when Caitlin’s headaches were worse, her anxiety also increased.
Over the years, Caitlin found yoga, Pilates, and exercise to be helpful in managing her anxiety. She also noted that cognitive-behavioral psychotherapy was very useful. Biofeedback was “not for her,” but she was able to use breathing techniques to calm herself down. As far as medications, she was prescribed fluoxetine (Prozac) and later switched to escitalopram (Lexapro). The selective serotonin reuptake inhibitor (SSRI) helped her anxiety, but not the migraines. She did take alprazolam (Xanax) for acute, severe anxiety.
She was switched to serotonin norepinephrine reuptake inhibitors (SNRIs), starting with duloxetine (Cymbalta) and then desvenlafaxine (Pristiq). These agents helped to treat the anxiety and, to a lesser extent, the migraines. A course of gabapentin did not help the anxiety or the headaches. Caitlin feels that with therapy and medications, she remains anxious but is significantly improved.
Caitlin’s history is fairly typical; anxiety may change over time, both in form and in severity. The search for effective medications may take time, as there is no accurate predictor of who will do well with what medication.
What Is Anxiety?
Anxiety is a necessary and universal emotion. With anxiety that originates from a real or perceived threat of danger, one experiences an increase in heart rate, blood pressure, diaphoresis, and other physical accompaniments to anxiety. At times, anxiety comes across as excessive worrying, and this leads to avoidant behavior. Hypervigilance is an excessive focusing of one’s attention on a possible danger or perceived danger.
When we think of anxiety, it is usually revolving around a problem or threat in the future. Fear, on the other hand, can be a very intense emotional reaction to a danger or threat that is in the present. We react to immediate dangers with the “fight-or-flight” response. Fear and anxiety, to some extent, are crucial for our existence. Fear allows us to escape from imminent threats; anxiety allows us to prepare for future problems. Anxiety, at least in low or moderate amounts, helps motivate many people to achieve. When someone crosses from moderate to high anxiety, it usually will interfere with the ability to perform.
The triggers for fear and anxiety may be internal or external. With internal triggers, one may have panic attacks that accelerate, feeding on themselves, in part because the associated tachycardia can convey the message that a serious physical problem is imminent. External triggers involve situations that may trigger phobias, or severe anxiety. These may include social situations, crowded or closed-in spaces, tests or other performances, etc. This leads to avoidant behavior, as anxious patients will tend to avoid those situations.
Types of Anxiety
Separation Anxiety Disorder
Patients with separation anxiety disorder have a fear of leaving a close relationship, such as the parent or home situation. Separation anxiety begins in childhood, and may or may not continue later on in life. It may manifest itself for the first time in kindergarten, with the child hanging onto the mother. Approximately 5% of the adult population has had the symptoms of separation anxiety. Separation anxiety may morph into a panic disorder or GAD.
Panic attacks occur with a number of physical symptoms that may include feelings of choking, trembling, diaphoresis, racing heart, shortness of breath, chest pain, fears of losing control or dying, numbness, chills or flushing, dizziness, lightheadedness, or fainting. Panic attacks usually reach their peak quickly, and last minutes to 1 or 2 hours. While they may be triggered by situations such as having to speak in public, they often occur without any obvious external trigger. Panic attacks may occur with agoraphobia, which involves a fear of situations where escape is not easy. These include public places and crowds, public transportation, highway driving, being on a bridge, or in an elevator or other enclosed space, being far from home or alone, or being stuck at a party. Agoraphobia such as this may occur without panic disorder.
Generalized Anxiety Disorder
GAD involves excessive worrying, which may be about school, work, family, health, finances, or the outside world. With GAD, most people worry on a daily basis, not just occasionally. To diagnose GAD, the worrying must have been present for at least 6 months. People with GAD don’t worry about just one facet of life, but many things. The worry becomes completely out of proportion to the significance of the problems. They also feel the physical aspects of anxiety, such as feeling “keyed up,” having concentration problems, insomnia, irritability, anger, or fatigue. Approximately 5% to 6% of the population suffers from GAD. It is more common in women than in men.
Social Anxiety Disorder
Social anxiety disorder, also known as SAD, is common during adolescence, particularly with the onset of dating, parties, and other social events. It may persist into the adult years. Public speaking is difficult for those with SAD, and this and other triggers can lead to avoidant behavior. Approximately 12% of the population experiences SAD at some point.
OCD often has an onset in early adolescence. The obsessions are intrusive, and distressing thoughts become focused on one or more concerns: germs or other contaminants, a need to have things arranged perfectly, a fear of hurting someone close, somatic (body) obsessions, hoarding, or sexual or religious obsessions. Compulsions are actions that reduce the person’s anxiety somewhat, and are triggered by the obsessions. Compulsions can take the form of obsessive checking (particularly things like locks or a stove), repeated cleaning routines, repetition of words, prayers or actions, counting, or arranging objects over and over. As with most anxiety symptoms, OCD may wax and wane over time.