Chronic Migraine: An Interactive Case History, Part 3
This is the third part of our series titled “Chronic Migraine: An Interactive Case History.” Our previous articles1,2 followed the diagnosis of a complex patient with the pseudonym “Heather” from age 24 to 30. To recap, Heather has been suffering from migraine and chronic daily headaches (CDH) with neck pain. She has medical diagnoses of irritable bowel syndrome (IBS) and fibromyalgia (FM).
History: Heather is a 30-year-old hairdresser in a salon. Her work can be very physical, and her life has not been easy. She has an ex-boyfriend, Eric, who was abusive; she also was abused by her mom, Sandy, an alcoholic. A few months ago, Heather ended her relationship with Eric. Now she is trying to turn her life around and is taking college classes at night. She has a new boyfriend, Steve, who is 15 years older and has 2 kids of his own. Heather is currently on 50 mg of topiramate and 25 mg of quetiapine to prevent headaches but cannot tolerate higher doses of either medication. Her irritability and anxiety have complicated her relationships with Steve and her co-workers at the hair salon. Heather is asking us: “Can you give me something else for my moods?”
Heather’s case is further complicated by chronic, mild bipolar depression and anxiety. She has been prescribed topiramate to prevent the migraines, which has helped but causes some side effects, including memory problems and paresthesias. Heather has also been taking a small dose, 25 mg, of quetiapine with the following abortive agents: 100 mg oral sumatriptan, zolmitriptan nasal spray, naproxen, ondansetron (for nausea), and hydrocodone in limited amounts. Botox injections were also helpful.
In addition to medications, Heather exercises, does yoga and biofeedback, and has seen a psychotherapist. Acupuncture and massage have not been useful.
What Treatment Options Should Be Considered?
As noted, Heather’s mood has been diagnosed on the mild end of the bipolar spectrum. When you suspect a patient may have a mood disorder, it is important to look for signs of a persistently agitated personality, with frequent cyclical depression or excessive energy, and a strong family history of either bipolar disorder or major depressive disorder. A family history of drug and/or alcohol abuse is also common. A clear hypomanic or manic episode may, however, not be evident. It is crucial to speak with a family member—at least 40% of the time, hypomania is not mentioned or recognized when we simply speak with the patient.
Other mild bipolar signs include early onset of depression (teen years), quick onset of depression, severe depression “for no reason,” opposite reactions to certain medications (such as being up all night with sedatives, mind racing from antidepressants, etc), very high anxiety, insomnia, persistent agitation, a moody personality, and a poor response to antidepressants. Hypomania may manifest itself as a cycle of irritable, brooding pessimism. Depression is the primary problem, much more than the hypomania. Left untreated, self-medication is common.
Whereas a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) may be the treatment of choice for Heather’s mood disorder, these may trigger hypomania. In the past, lamotrigine increased her headaches but did help her mood significantly, whereas oxcarbazepine and sodium valproate gave her side effects.
We decide to add a small amount of an atypical antipsychotic, aripiprazole, to Heather’s regimen. Aripiprazole contains the same class warnings as the other atypical antipsychotics (primarily the risk for diabetes) but is much less apt to cause significant weight gain. With patients with headache who have psychiatric comorbidities, it is best to begin with low doses of medications. We usually begin with tiny doses (1/2 of a 2-mg tablet, slowly increasing to 5 or 10 mg). The common side effects associated with aripiprazole include akathisia, fatigue, headache, nausea, constipation, dizziness, insomnia, and visual disturbances.
Heather is begun on 1 mg of aripriprazole, increasing to 2 mg after 6 days. She is continued on her preventive regimen of 50 mg of topiramate and 25 of quetiapine. Oral sumatriptan has become ineffective for her migraines. Although the zolmitriptan nasal spray does help, it is no longer covered under her medical insurance. Financial considerations often dictate which medications we prescribe. The other generic triptan, naratriptan, is prescribed for Heather; she may use naratriptan with naproxen at the same time.
Six weeks later, Heather calls and states that she is pregnant.
How Does Pregnancy Affect Treatment?
Prior to her pregnancy, we had discussed the risks of taking headache medications with Heather. She and Steve had not planned on having a child right away. So, we now quickly taper her off the headache medications; whether to continue psychiatric medications during pregnancy is a difficult, case-by-case decision.
Our medication choices during pregnancy are limited. For headache treatment, acetaminophen is useful. The addition of caffeine may be beneficial. The triptans are pregnancy category C agents and therefore not recommended during pregnancy. Although the ongoing sumatriptan pregnancy registry indicates that incidental use of sumatriptan during pregnancy may be relatively safe, we attempt to avoid its use during pregnancy, as the risk of sumatriptan, like most of our medications, is not definitively known.
In addition, we avoid barbiturate-containing drugs, such as butalbital. Prednisone, in very limited amounts, may be considered; opioids, also in limited amounts, are relatively safe but do have possible congenital side effects. Ondansetron, over-the-counter Emetrol, and metoclopramide can be used for nausea during pregnancy.
For treatment of Heather’s headaches, we prescribe ice, biofeedback/relaxation, acetaminophen with limited amounts of caffeine, minimal amounts of hydrocodone, and ondansetron for nausea.
As for preventives, propranolol, in limited amounts, has been used during pregnancy. Verapamil has also been used and has relatively few risks during pregnancy. Magnesium and omega-3 fatty acids may be used. Most medications, such as topiramate, are pregnancy category C agents, and the risks are not definitively known. Tricyclic antidepressants (TCAs) are best avoided.
With regard to psychotropics, the atypical antipsychotics (quetiapine, aripiprazole, etc) may turn out to be relatively safe, but definitive answers on these are still pending. There is a “neonatal SSRI syndrome,” with the infant showing signs of jitteriness, increased muscle tone, irritability, and respiratory distress. Up to 30% of infants exposed to SSRIs during the third trimester may have this syndrome.