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Case History of Chronic Migraine: Update 2015

This case was first presented in 2008. Dr. Robbins has updated the case to reflect changes in pain management. To follow is a step-by-step guide through the continued diagnosis and treatment of a refractory complex headache patient.
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Heather is a 24-year-old hairdresser with migraines since age 12, which have been slowly increasing. In the last 3 years, she has endured daily headaches. Her mother and sister also have migraines. Her usual daily headache is an aching, throbbing moderate headache with photophobia. About 6 times per month, Heather has a moderate to severe migraine with nausea and lasting one day. She has been diagnosed with chronic migraine (CM). Triggers for her more severe migraines include weather changes, stress, and menstruation (1 day prior to her menses).

Heather has also struggled with Irritable Bowel Syndrome (IBS) for much of her life; she has occasional constipation, but diarrhea and cramps are her usual symptoms. She has not been treated for this. She is 5’5,” weighs 128, and has, at times, struggled with weight gain. She does not smoke cigarettes.

Besides the daily headache, Heather has associated neck pain, with tenderness in her neck and shoulder muscles. She clenches and grinds her teeth, particularly at night while sleeping. She was prescribed diazepam, but says, “I became wired and had a bad reaction on it…”

Heather has not been on daily preventives. She consumes four Extra Strength Excedrin daily and, for her migraine, uses hydrocodone. This dampens the pain but does not help any more than 30%.

Psychological Aspects

Heather also has been diagnosed with generalized anxiety disorder and depression. She first became depressed at age 14, and has had mild-to-moderate chronic depression since age 18. There is a strong family history of anxiety and depression. Her grandmother was hospitalized for possible depression, and an uncle committed suicide. Heather’s mom suffers from lifelong depression and has struggled with alcoholism.

Heather is chronically irritable and somewhat angry; she is prone to bouts of road rage. She has several spells a year which she describes as “too much energy, where I don’t sleep much.” In certain seasons, she seems to cycle into worsening depression.

Heather was placed on fluoxetine, and she “was up all night, my mind was going too fast.” She was then prescribed duloxetine, and the same thing happened. Heather also becomes “wired” from certain medications, such as pseudoephedrine.

In summary, Heather has moderate daily headache, with migraines 6 times a month, plus anxiety and depression, IBS, and neck pain.

Q: Outside of Medication, What Would You Suggest For Heather?

We need to teach Heather about regular sleep habits, not missing meals, avoiding too much caffeine, identifying stresses that may contribute to her headaches, engaging in exercise and improving posture, etc.

In addition, a referral to a good psychotherapist would be beneficial, as would biofeedback by a skilled therapist. Psychiatric referral would be a reasonable choice as well.

For the neck pain, physical therapy may be helpful, at least as far as teaching about exercise and posture. Heather’s profession as a hairdresser often will exacerbate neck pain and her headaches due to the constant arm movements. A dentist who is adept at evaluating temporomandibular disorders (TMD) may be beneficial for Heather as well.

We do not expect Heather to rush off to the psychologist, psychiatrist, physical therapist, and dentist all at once. Because of money and time, most patients carefully select which healthcare professionals they visit. However, it ‘takes a village’ to treat a complicated pain patient and I try to refer the patient to appropriate specialists.

Diagnosing Type of Depression Key

We need to think about the mild end of the bipolar spectrum. According to one study, 8.6% of migraineurs fit into the bipolar spectrum. Heather has a number of features of bipolar disorder, including early-onset depression (age 14) and a family history of depression, suicide, and substance abuse. Other indicators are her irritable/angry personality, cyclical depression, spells of too much energy, and poor (bipolar) reaction to certain medications (antidepressants, pseudoephedrine, diazepam). The clinical stakes for missing bipolar disease are enormous. Patients such as Heather tend to bounce from antidepressant to antidepressant, with predictably poor results.

Q: What Are the Initial Choices of Preventive Medication for Heather?

Comorbidities, along with the headache characteristics, guide where we go with the headache medications. Along with the chronic daily headaches and migraines, Heather fits the mild end of the bipolar spectrum, has IBS (primarily diarrhea), neck pain, and has struggled with weight gain. All of these characteristics figure into our medication choices.

As a headache preventive, topiramate may be a good choice. It will not cause weight gain and may decrease appetite for some period of time. It may act as a mild mood stabilizer, although studies have reported both positive and negative results on topiramate as a bipolar medication. Topiramate may almost certainly exacerbate depression. We would begin with a low dose because headache patients tend to be somatic and will not tolerate large initial doses—often leading to them quitting the medicine prematurely.

My recommendation would be: topiramate, 25 mg, one at night for the first 6 nights. If that initial dose is tolerated, I would suggest increasing to 50 mg at night. Utilizing the topiramate at night may minimize cognitive side effects and fatigue. Some patients cannot tolerate more than 25 mg of topiramate. The usual dose is 50 mg to 100 mg, although some patients do well on 25 mg, while others require 300 or 400 mg per day.

The cognitive side effects of spacey feelings and memory problems often limit topiramate’s use, as does the tingling sensation in fingers and toes. Primarily due to carbonic anhydrase activity, the tingling is sometimes offset via the use of potassium—either natural or in tablets/powder. There is now a longer-acting form, generic topiramate ER.

Q: Which Abortive Medication Would You Consider?

Most daily headache patients take 2 or 3 abortive medications. They may have something for milder daily headaches, a migraine medication, and an “escape” analgesic for the severe migraine. With Heather, we do not want to go down the road of overused daily analgesics, but most patients want and need something for the daily headaches as well as for the migraine. In Heather’s case, we need to emphasize that we do not want to constantly chase the headache all day, but rather use the preventive medications and non-medication techniques to decrease the severity.

For Heather’s migraines, my recommendation would be oral sumatriptan at 100 mg. If patients have never used a triptan before, I start with a low dose the first time—such as half of a tablet. The muscle pressure, tingling, and other side effects of the triptans frighten many patients, and so we need to start patients on a low initial dose. This go-slow strategy should improve compliance. With the triptans and other anti-migraine abortive medications, early intervention is crucial. There is an enormous difference in symptom response between using the triptan in the first 30 minutes of a migraine, and waiting an hour or more.

Last updated on: August 11, 2015
First published on: June 1, 2015
Continue Reading:
Case History of Chronic Migraine: Update 2015 Part 2