jmj11 Posted July 31, 2011 Author Share Posted July 31, 2011 I saw a 49 year old woman three weeks ago and her is her HPI: Episodic migraine going back to age 12. Never been much of a problem occurring once a month. Last year her headaches slightly increased (as she was in the middle of menopause) to 2-3 times a month. On Nov 12th, 2010 she developed a horrible migraine . . . and as of three weeks ago (that's eight months later) had not changed. It was a 8-10/10 with her usual associated symptoms. You can take your thinking caps off now, nothing exotic. This is migraine and nothing else (all tests were fine). The patient was treated by her PCP with SSRIs, Ativan and narcotics. Then she sent her to the local neurologist who treated her with Topamax. All failed but the narcotics numbed up her head a bit and gave her some relief so she started eating them like candy to maintain her sanity. Both the PCP and neurologists called this "Chronic Tension-Type Headaches" and said it was related to stressors in her life. They had arranged for her to see several therapists. Her PCP also said she was a drug seeker (had been in the ER 3-4 times for injections and in the PCP's office). Neither the PCP nor the neurologist referred her to me (even though I know both of them well). A friend of her's saw our ad and suggested she see me. She had the type of insurance that did not require a referral. After I saw her, I sent a letter to both the PCP and neurologists telling them of our plan. The PCP called me and told me how I was wasting my time. That this lady was a drug seeker and her husband wasn't the nicest man in town and she is confident that the patient needs to handle her stress and all this would get better. I felt sad about that call. Three weeks ago I spent 90 minutes with this lady and her husband. They were at the ends of their ropes. I created a complex and aggressive treatment plan because I saw her slipping over the edge in distress from an unrelenting migraine for eight months. Friday she comes down the hall, grabs me and gives me a big hug. She is so excited to pull out her calendar and show me how her headaches slowly gone down from 8-10 every day, to finally 1-2 and a couple of missed days. She gave me a $50 Starbucks card. She is off all controlled substances and elated. The WHO says that headache is one of the top 50 most disabling medical conditions. Of the top five, headache is the most poorly treated. I sincerely believe that headache patients are discriminated against because of very, very old stereotypes. I'm starting to prepare for the PANRE and have been reading example questions. The headache questions are terrible and imply old stereotypes from the 60s. It would be the same as if a question had the correct answer that Menthol Cigarettes are one of the best treatments for Asthma. Link to comment Share on other sites More sharing options...
jmj11 Posted July 31, 2011 Share Posted July 31, 2011 I saw a 49 year old woman three weeks ago and her is her HPI: Episodic migraine going back to age 12. Never been much of a problem occurring once a month. Last year her headaches slightly increased (as she was in the middle of menopause) to 2-3 times a month. On Nov 12th, 2010 she developed a horrible migraine . . . and as of three weeks ago (that's eight months later) had not changed. It was a 8-10/10 with her usual associated symptoms. You can take your thinking caps off now, nothing exotic. This is migraine and nothing else (all tests were fine). The patient was treated by her PCP with SSRIs, Ativan and narcotics. Then she sent her to the local neurologist who treated her with Topamax. All failed but the narcotics numbed up her head a bit and gave her some relief so she started eating them like candy to maintain her sanity. Both the PCP and neurologists called this "Chronic Tension-Type Headaches" and said it was related to stressors in her life. They had arranged for her to see several therapists. Her PCP also said she was a drug seeker (had been in the ER 3-4 times for injections and in the PCP's office). Neither the PCP nor the neurologist referred her to me (even though I know both of them well). A friend of her's saw our ad and suggested she see me. She had the type of insurance that did not require a referral. After I saw her, I sent a letter to both the PCP and neurologists telling them of our plan. The PCP called me and told me how I was wasting my time. That this lady was a drug seeker and her husband wasn't the nicest man in town and she is confident that the patient needs to handle her stress and all this would get better. I felt sad about that call. Three weeks ago I spent 90 minutes with this lady and her husband. They were at the ends of their ropes. I created a complex and aggressive treatment plan because I saw her slipping over the edge in distress from an unrelenting migraine for eight months. Friday she comes down the hall, grabs me and gives me a big hug. She is so excited to pull out her calendar and show me how her headaches slowly gone down from 8-10 every day, to finally 1-2 and a couple of missed days. She gave me a $50 Starbucks card. She is off all controlled substances and elated. The WHO says that headache is one of the top 50 most disabling medical conditions. Of the top five, headache is the most poorly treated. I sincerely believe that headache patients are discriminated against because of very, very old stereotypes. I'm starting to prepare for the PANRE and have been reading example questions. The headache questions are terrible and imply old stereotypes from the 60s. It would be the same as if a question had the correct answer that Menthol Cigarettes are one of the best treatments for Asthma. Link to comment Share on other sites More sharing options...
Contrarian Posted July 31, 2011 Share Posted July 31, 2011 Great Job...!!! So I guess I'll have to stop Rx-ing "2 mentol cigs q 2 hrs PRN for RAD exacerbation; NTE 40cigs/24hrs"... :;;D: Link to comment Share on other sites More sharing options...
Contrarian Posted July 31, 2011 Share Posted July 31, 2011 Great Job...!!! So I guess I'll have to stop Rx-ing "2 mentol cigs q 2 hrs PRN for RAD exacerbation; NTE 40cigs/24hrs"... :;;D: Link to comment Share on other sites More sharing options...
jmj11 Posted July 31, 2011 Author Share Posted July 31, 2011 Great Job...!!! So I guess I'll have to stop Rx-ing "2 mentol cigs q 2 hrs PRN for RAD exacerbation; NTE 40cigs/24hrs"... :;;D: That's right. Not only do you look more sexy, you can breath better. Hey, I'm closing up the laptop and heading to your neck of the woods. Meeting friends to kayak on Lake Padden (one lake removed from yours). Link to comment Share on other sites More sharing options...
jmj11 Posted July 31, 2011 Author Share Posted July 31, 2011 Great Job...!!! So I guess I'll have to stop Rx-ing "2 mentol cigs q 2 hrs PRN for RAD exacerbation; NTE 40cigs/24hrs"... :;;D: That's right. Not only do you look more sexy, you can breath better. Hey, I'm closing up the laptop and heading to your neck of the woods. Meeting friends to kayak on Lake Padden (one lake removed from yours). Link to comment Share on other sites More sharing options...
xxbowiexx Posted July 31, 2011 Share Posted July 31, 2011 Sounds like there's one less headache to deal with, great job :) Link to comment Share on other sites More sharing options...
xxbowiexx Posted July 31, 2011 Share Posted July 31, 2011 Sounds like there's one less headache to deal with, great job :) Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 31, 2011 Moderator Share Posted July 31, 2011 Great Job...!!! So I guess I'll have to stop Rx-ing "2 mentol cigs q 2 hrs PRN for RAD exacerbation; NTE 40cigs/24hrs"... :;;D: I thought "only your doctor" could prescribe menthol cigarettes for rad and that they have to take a special class first.... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 31, 2011 Moderator Share Posted July 31, 2011 Great Job...!!! So I guess I'll have to stop Rx-ing "2 mentol cigs q 2 hrs PRN for RAD exacerbation; NTE 40cigs/24hrs"... :;;D: I thought "only your doctor" could prescribe menthol cigarettes for rad and that they have to take a special class first.... Link to comment Share on other sites More sharing options...
acozadd Posted July 31, 2011 Share Posted July 31, 2011 So how did you treat her if you don't mind me asking? Link to comment Share on other sites More sharing options...
acozadd Posted July 31, 2011 Share Posted July 31, 2011 So how did you treat her if you don't mind me asking? Link to comment Share on other sites More sharing options...
jmj11 Posted August 1, 2011 Author Share Posted August 1, 2011 So how did you treat her if you don't mind me asking? As you know most women see an improvement in their migraines after menopause. However, for an unfortunate few, the drop in estrogen can, at first at least, put them into a migraine tailspin. She had a bad migraine that turned into status and then simply evolved into Chronic Intractable Migraine. She may or may not have had medication overuse headache (previously known as rebound) superimposed as she was taking a mixed bag of hydrocodone, codeine+butalbital, sumatriptan, one or the other on a daily basis. However, the only way to dx medication overuse syndrome is to have them go off the offending meds, then within three months they get much better with no other intervention. In her case my original plan was this: Wk 1: a) Taper off the toprimate over 4 days and dc b) Day 5 of wk 1, start zonisamide 50 MG/day. c) Try to softly start backing off of the analgesics and sumatriptan d) Start magnesium 400 MG/ day + butterbur herb (those are like pissing into the wind with headaches this bad but they won't hurt) Wk 2: a) Raise zonisamide to 100 MG/ day, b) Stop all sumatriptan c) Start self-injections of DHE-45 1 mg sq bid. d) Begin an aggressive taper of analgesics as I've drew it out. Follow up at the end of week three. However, as I discussed the self-injections, she was needle phobic and he husband wasn't interested in learning. So we made the following substitution: Wk 2 She started methergine .2 mg tid after reading and signing my methergine warning and consent form. At the beginning of week three she raised the methergine to 2- .2 MG tid. The plan will be to start tapering the methergine in another 4 weeks and titrate upward on the zonisamide, if needed. I am seeing her back in three weeks. However she is off all analgesics and triptans now so we are a giant step in the right direction. Link to comment Share on other sites More sharing options...
jmj11 Posted August 1, 2011 Author Share Posted August 1, 2011 So how did you treat her if you don't mind me asking? As you know most women see an improvement in their migraines after menopause. However, for an unfortunate few, the drop in estrogen can, at first at least, put them into a migraine tailspin. She had a bad migraine that turned into status and then simply evolved into Chronic Intractable Migraine. She may or may not have had medication overuse headache (previously known as rebound) superimposed as she was taking a mixed bag of hydrocodone, codeine+butalbital, sumatriptan, one or the other on a daily basis. However, the only way to dx medication overuse syndrome is to have them go off the offending meds, then within three months they get much better with no other intervention. In her case my original plan was this: Wk 1: a) Taper off the toprimate over 4 days and dc b) Day 5 of wk 1, start zonisamide 50 MG/day. c) Try to softly start backing off of the analgesics and sumatriptan d) Start magnesium 400 MG/ day + butterbur herb (those are like pissing into the wind with headaches this bad but they won't hurt) Wk 2: a) Raise zonisamide to 100 MG/ day, b) Stop all sumatriptan c) Start self-injections of DHE-45 1 mg sq bid. d) Begin an aggressive taper of analgesics as I've drew it out. Follow up at the end of week three. However, as I discussed the self-injections, she was needle phobic and he husband wasn't interested in learning. So we made the following substitution: Wk 2 She started methergine .2 mg tid after reading and signing my methergine warning and consent form. At the beginning of week three she raised the methergine to 2- .2 MG tid. The plan will be to start tapering the methergine in another 4 weeks and titrate upward on the zonisamide, if needed. I am seeing her back in three weeks. However she is off all analgesics and triptans now so we are a giant step in the right direction. Link to comment Share on other sites More sharing options...
bradtPA Posted August 1, 2011 Share Posted August 1, 2011 What about estrogen supplementation for tx in this case? Resonable? Historically, sounds like she had menstrual migraines for years, then the drop at menopause put her in a tailspin. Link to comment Share on other sites More sharing options...
bradtPA Posted August 1, 2011 Share Posted August 1, 2011 What about estrogen supplementation for tx in this case? Resonable? Historically, sounds like she had menstrual migraines for years, then the drop at menopause put her in a tailspin. Link to comment Share on other sites More sharing options...
jmj11 Posted August 1, 2011 Author Share Posted August 1, 2011 What about estrogen supplementation for tx in this case? Resonable? Historically, sounds like she had menstrual migraines for years, then the drop at menopause put her in a tailspin. Unfortunately that usually doesn't work. It is like the patient's brain is in tune to her estrogen and replacement therapy, although there are exceptions, usually doesn't help. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.