Chronic Migraine: An Interactive Case History
New patient “Heather” (not her real name) is a 24-year-old hairdresser with migraines since age 12, which have been slowly increasing. In the last three 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 six 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 menstrual (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%.
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 Cymbalta, and the same thing happened. Heather also becomes “wired” from certain meds, such as pseudephedrine.
In summary, Heather has moderate daily headache, with migraines six times a month, plus anxiety and depression, IBS, and neck pain.
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 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.
What type of depression does Heather suffer from?
We need to think about the mild end of the bipolar spectrum. According to one study, some 8.6% of migraineurs fit into the bipolar spectrum. Heather has a number of features of bipolar disorder, including early 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 meds (antidepressants, pseudoephedrine, diazepam). The clinical stakes for missing bipolar are enormous. Patients like Heather tend to bounce from antidepressant to antidepressant, with predictably poor results.
Question: What are the initial choices of preventive medication for Heather?
Comorbidities, along with the headache characteristics, guide where we go with the headache meds. Along with the chronic daily headaches (CDH) 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 quit the medicine prematurely. My recommendation would be: topiramate, 25mg, one at night for the first 6 nights then, if tolerated, increasing to 50mg at night. Utilizing the topiramate at night may minimize cognitive side effects and fatigue. Some patients cannot tolerate more than 25mg of topiramate. The usual dose is 50mg to 100mg, although some patients do well on 25mg, while others require 300 or 400mg 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.
Which abortive meds would you consider?
Most daily headache patients have two or three abortives. 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 meds and non-medication techniques to decrease the severity.
For Heather’s migraines, my recommendation would be sumatriptan, 100mg tabs. If patients have never used a triptan before, I start with a low dose the first time—such as half of a tablet. Many patients are frightened by the muscle pressure, tingling, and other side effects of the triptans, and we need to test them on a low initial dose. This will improve compliance. With the triptans and other antimigraine abortives, early intervention is crucial. There is an enormous difference between using the triptan in the first half hour and waiting an hour or more.
For Heather’s nausea, we prescribe 8mg ondansentron as this is the only antiemetic that is non-sedating. We stop the hydrocodone, except as an “escape” medication to be used on a very limited basis.