Tuesday, November 8, 2011

Persistent Headache in a 35 year old Woman

I was working in the urgent care clinic when I went into see my next patient.  She was a 35 year old who was sitting on the exam table, holding her head in her hands, looking down at the floor.  It seemed my entrance into the room didn’t even stir her. 
“Hi, I’m Sharon,” I said to the unmoving patient. 
“I’m Shelly,” was her response.
“How can I help?”
Without moving again, Shelly replied, “I ran out of my Imitrex and I need some for this migraine headache I have right now.”
“I see.  Well what can you tell me about your migraine history?”
“Is there anyway to dim those overhead lights?” Shelly asked.
“Well, I can turn them off and just use these smaller desk lights if that will help.”
“Yes, please,” she sighed.
I turned off the overhead lights and walked back over to the desk to turn on the smaller desk lamps.  The room was definitely darker.   With that, Shelly let out her sigh of relief and sat upright. 
“Is that better?”
“Yes, thanks.  You asked about my migraine history.  I’ve had migraines since I was in college.  Maybe it was the stress that brought them on, I don’t know.  But back then my family physician totally worked me up for them with a CT scan, some lab work and didn’t find anything.  He treated me with naprosyn which after two years quit working.  Then I was switched over to Cafergot, which worked until I had my first child 10 years ago.  At that point he wanted me to see a neurologist.  So I saw Dr. Hummel, who’s wonderful. “

Migraines affect 12 perecent of all patients.  It’s more frequent in women than men, and it’s most common in those aged 30-39. 
There are some typical factors that will trigger a migraine.  These can include: 1) menstrual changes, 2) emotional stress, 3) not eating, 4) changes in weather, 5) sleep disturbances, 6) odors, 7) alcohol, 8) lights, 9) smoke, 10) neck pain, 11) heat, 12) foods, 13) exercise, 14) sleeping in.  Obesity is associated with an increased frequency and severity of migraine. 

Typicallly there are four stages of a migraine.  Prodrome (24-48 hours prior) which can include euphoria, depression, food cravings, constipation, etc.  Aura: this can involve visual changes, sensory changes, verbal or motor disturbances.  Migraine headache: tends to be throbbing or pulsatile, typically on one side of the patient’s head, nausea, vomiting, problems with light sensitivity or sound sensitivity.  Then there is the postdrome: after the headache is gone patients can feel drained or exhausted. 

Migraines, if left untreated can last at long as four hours or be around for as long as several days.  There are several different forms of migraine: menstrual migraine (those migraines associated with the patient’s menstrual cycle, they can show up two days prior to the cycle and stay around for 3 days into it), basilar-type, ocular migraine, migraine headache without aura. 

“Dr. Hummel looked over my records and thought I might have menstrual migraine seeing that I quit responding to Cafergot with my pregnancy.  So he decided to try and treat me with a low dose of Inderal for 6 days a month, 3 days prior to my period and 3 days into my cycle.  That has really helped me out.  It’s dropped my migraines down from 2-3 a month to usually one a month.  The migraine I have with my period is gone but I still get one about mid-cycle, which is where I am right now. “
“Dr. Hummel gives me imitrex to take for the headache I get in my mid-cycle.  But I’ve run out of them and I don’t see him again until next month.  I generally have to take an Imitrex twice a day for two days and that takes care of my migraine. “
“So where are you right now, have you taken any Imitrex for this headache?”
“I had two left, so I took them yesterday, but I didn’t have any for today and my headache has just rebounded back without the imitrex.”
“Okay, so knowing that you were going to run out of your Imitrex before you saw Dr. Hummel, why didn’t you call his office and get a refill of it until you saw him next month?”
“Well, I called his office and I was told he was on vacation and therefore my refill wouldn’t be taken care of until he returns on Monday.”
“I see.  So what medications are you on?”
“I take Imitrex for the two days once a month for my migraine, I’m on Inderal for 6 days a month.  I also on a birth control pill, yaz.”
“Okay, anything else in your medical history?  Any high blood pressure, diabetes, etc?”
“No, just my migraines.”
“Are you allergic to anything?”
“Does anyone in your family have a history of migraines?”
“My aunt has them, I’ve been told.”
“Alright, well then let me do a quick physical exam and then I’ll refill your Imitrex prescription until you can get into to see Dr. Hummel again.”
The patient didn’t have anything significant on her physical exam, which included her neurological exam which was normal. 
“Okay, Shelly, what dose of Imitrex do you take?”
“Dr. Hummel has me on 25 mgs. of Imitrex twice a day when I have the migraine and it makes it go away.  Sometimes I have to take the Imitrex three times a day, like every 8 hours instead of just taking two a day.  That’s what happened with me last month.”
“What about any nausea, do you take any meds for that?”
“I don’t have any nausea, if I take my Imitrex soon enough.”
“Alright, well then here’s you a refill of your Imitrex medication, it should get you through next month until you see Dr. Hummel again, okay?”
“With a heavy sigh of relief, Shelly took the prescription from me and left the exam room. 

There are various treatments for migraines.  They can involve acute therapy, chronic prophylaxis (prevention of the headache), and avaidance of triggers. 

Acute therapy can include: Tylenol, NSAIDs (naprosyn, motrin, etc), ergotamine medications (Cafergot), and triptans (Imitrex and 4 other triptans).  Chronic prophylaxis for migraines include: blood pressure medications (beta blockers such as Inderal), ace inhibitors, calcium channel blockers, angiotension receptor blockers, Elavil, or even CoQ10 enzyme supplement.    

1 comment:

  1. Following posted to this site on 12/15/11: http://amyjane.hubpages.com/hub/New-Daily-Persistent-Headache
    My deepest empathy for all chronic headache sufferers. I pray God will heal you or lead you towards relief. I essentially have had a headache nearly everyday for decades. I have been to dozens of doctors of different types (medical, chiropracic) with various specialties, have taken many different drugs, and have had many tests. I could spend hours on my headache history but can't now. I will highlight solutions that have worked for me Suffices to say that I have had two septoplastys and have taken many drugs. The surgeries helped but did not relieve. I was using Ambien to help me sleep. I discovered Ambien was causing me to be susceptible to migraines. I also noticed that if I took an additional dose of Ambien upon waking in the middle of the night, a nasty headache or migraine was certain. After switching to Lunesta, I had much fewer migraines. Later, I eliminated Lunesta and rarely have a migraine. When I felt a migraine coming on, I would take 400 mg of ibupropen and lay down with an ice pack on my head. Usually within 30-40 minutes after taking the ibupropen and applying the ice pack, most of my migraine was relieved. I have been off all drugs for about 2 1/2 months. I believe my body and sleep are being restored to normal because I am off drugs. That is one reason why my headaches are much better. The other reasons are avoidance of triggers: weather changes, allergens, high stress. In addition, I relax several times per day and sleep on my side at night. I still have chronic headache that is worse in the morning but often dissipates to low level at night as long as I avoid triggers. Laying down and applying an icepack helps relieve the headache. I believe I still have daily headaches because I am unemployed which is causing some stress and is probably disturbing my sleep. Our bodies and souls (mind, will, emotion) were not engineered to undergo continuous periods of stress, just as the lily was not engineered to undergo extremes of weather without damage. Do some research on neuropeptides and stress and you'll see what I mean. I truly believe that when I am fully able to obey what the Bible says (fear not, don't be anxious, pray, trust God completely, relax and be at peace, read the Word), and take excellent care of my body and soul, the daily headaches will disappear. Another method I've used to prevent and relieve headache is to take opportunities to laugh. As the Bible says "A merry heart does good like medicine." I sincerely hope this helps.

    Currently taking Nemanda which seems to help, even though it is primarily for alzheimers patients.