Chronic Migraine: An Interactive Case History, Part 2
Our patient Heather (not her real name) initially came in at age 24 and we chronicled her history and early treatment.1 In summary, Heather has moderate daily headache (CDH), with migraine 6 times per month. She also suffers from anxiety and depression (the mild end of the bipolar spectrum). Heather has irritable bowel syndrome (IBS; primarily diarrhea) plus neck pain. She was prescribed topiramate as a preventive with the following as abortives: sumatriptan, naproxen, ondansentron (for nausea), and occasional hydrocodone (see Appendix A for a complete list of generic/brand names of medications referred to in this article). Heather reports that the topiramate helped her headaches but possibly exacerbated her depression and caused mild memory disturbances. 50mg of topiramate is the most she can tolerate, as she experiences memory disturbances at a higher dose. Sumatriptan is only mildly helpful but over-the-counter naproxen is useful and ondansentron relieves her nausea. She exercises 20 minutes daily, sees a therapist, and is learning biofeedback. We added quetiapine, slowly increasing to 50mg at night, and substituted rizatriptan for sumatriptan. Quetiapine helps her moods but she cannot tolerate more than 25mg qHS. Rizatriptan was not all that helpful and during our last visit we prescribed zolmitriptan nasal spray.
Heather returned six months later at age 25. Her menstrual migraines are severe but zolmitriptan nasal spray helps (with naproxen) at least most of the time. Heather cycles in and out of depression, alternating with hypomania. She is chronically somewhat irritable and angry which interferes with relationships. Heather has had a rough go of it lately. She has a deadbeat boyfriend, Eric, who somehow neglected to inform her of his wife and two kids, and she also deals with an alcoholic, abusive mom (Sandy). Heather does not ruminate about suicide but occasionally wishes she were dead. She has no active suicidal plans. Heather loves her job, finds solace in the salon, but has been bickering with Alan, a new stylist who has been stealing some clients. So, along with headaches and neck pain, Heather is angry and depressed. She finds herself looking at every young, married woman with envy. Her two sisters are fairly supportive.
What Treatment Options Should Be Considered?
Of course, we have a long talk with Heather about psychotherapy. She is reluctant to go, due to money, time, and stigma. We push Heather, suggesting a “sliding scale” therapist or a publicly-funded therapy organization. We try to “de-stigmatize” going to therapy. I often say, ”If it was up to me, everybody in our country would see a therapist.” I have found that it may take many years of pushing and suggesting to convince reluctant patients to seek therapy.
Heather’s headaches are somewhat controlled on 50mg of topiramate and 25mg of quetiapine with the following abortives: zolmitriptan nasal spray, naproxen, ondansentron (for nausea) and occasional hydrocodone. Her moods are more of an issue at this point. We should search for medication options that may help Heather’s (mild) bipolar moods as well as the headaches. Possibilities include: lamotrigine, oxcarbazepine, sodium valproate, another atypical (such as aripiprazole) or lithium. Ideally, we would like to avoid antidepressants, although some with bipolar who are on an adequate mood stabilizer may tolerate antidepressants. Lamotrigine would be the first choice as it has minimal side effects (rarely does lamotrigine cause tiredness or weight gain). Oxcarbazepine is a mild (and often overlooked) mood stabilizer. While related to carbamazepine, oxcarbazepine has markedly fewer adverse effects. Sodium valproate may help moods as well as Heather’s headaches. However, valproate does tend to cause weight gain and fatigue and greatly increases risks with pregnancy. Heather is on quetiapine but another atypical—such as aripiprazole—could help as it does not tend to cause the weight gain and fatigue that quetiapine may produce. Lithium in low doses is often very effective. Lithium is probably underutilized in the “mild” bipolar population. However, with lithium, particularly in higher doses, weight gain, fatigue, and hypothyroidism somewhat limit it’s use.
We decide to proceed with lamotrigine, slowly increasing to 100mg daily. The risk with lamotrigine is Stevens-Johnson Syndrome (SJS) as well as toxic epidermal necrolysis (TEN). These serious systemic and skin reactions are only observed in approximately 1 in 2,500 patients on lamotrigine. A “regular” drug rash is often seen (in at least 10% of patients). With any rash, I stop the lamotrigine (or any drug new to the patient). Stevens-Johnson is an immunologically-based, severe form of erythema multiforme. SJS and TEN are probably manifestations (SJS at the milder end of the spectrum, TEN more severe) of the same disease process. SJS usually involves the mucous membranes and skin. With SJS, the male-to-female ratio is 2:1 in patients with a genetic predisposition. Infectious SJS begins with nonspecific upper respiratory infection (URI) symptoms, with a sudden onset of skin lesions. Drug causes are varied—from oxicam NSAIDs to sulfa to anticonvulsants. The more severe TEN implies more skin area involvement than is seen with SJS. TEN carries a mortality rate of 30 to 50% (while SJS has a mortality rate of 1 to 5%).
We give Heather 25mg of lamotrigine, to increase after 10 days to 50mg. Some patients do well on low doses (25mg), while others require 300 or 400mg per day. Heather calls three weeks later and reports that she has not had a rash but has had no improvement in moods. We increase the lamotrigine to 75mg for 10 days, then 100mg per day. She is, of course, instructed to discontinue lamotrigine with any rash.
Six weeks later, Heather comes in and states that her mood is significantly improved. She is less irritated and depressed, and her mind racing is less. She has been working out her work differences with Alan but the economy and decreased business helps fuel her depression. Mind racing may be a result of several conditions, particularly anxiety vs. mania (or hypomania). It is important to inquire as to the “quality” of the rumination and racing. If it is constant worry, anxiety is the likely cause. With hypomania, it may simply be random thoughts racing thru the brain and not necessarily connected to worry or anxiety.
Heather’s headaches are more severe on the lamotrigine. She is now on 50mg of topiramate as a headache preventive; 25mg of quetiapine for moods, sleep, headache; and 100mg of lamotrigine for moods (although lamotrigine may also alleviate headaches in some patients). It is possible that the lamotrigine has exacerbated Heather’s headaches. This is a common situation with comorbid conditions where we are juggling various meds: a drug may help one condition while worsening another. At this point, Heather’s moods are better on lamotrigine but headaches are more severe.