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Headache Case

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Okay, this may not go far but I thought I would throw it out. This is not a trick "try and make the diagnoses" case, but a simply management presentation. So don't waste your time trying to come up with a new diagnosis . . . it is simply Chronic Migraine, with out aura, with intractable.


This is a patient, whom I saw yesterday. She is not the most complex patient I see, but she is more complex than the typical. She came over 100 miles to see me.


A 62 year old lady began developing episodic migraines without aura in her teens. With each of three pregnancies they got worse. Finally, about age 42, They became daily, with about 4-5 days a week over a 8/10 in severity.


In the twenty years since they have been so severe, she has been follow by three regional headache clinics and all have failed.


Her present symptomatic treatments are sumatriptan injections and oral 100MG tablets, using about 18 total per month. She takes 4 Fioricet per day and uses a Vicodin ES about twice a week. About once a month she has to go to the ER.


Prior treatments:


Preventative medications: nortriptyline, amitriptyline, propranolol, nadolol, verapamil, topiramate, valproate, pregablin, gabapentin, virtually all the SSRI and SNRI drugs . . . all of these were used at therapeutic doses and none helped. Cervical injections including trigger point and facet blocks. Three courses of Botox treatments. Those did not help either.


CAM tried: acupuncture, chiropractic, massage, Yoga, TMJ work (I consider as "alternative"), biofeedback, many mental health therapists, naturopathic, many different diets and supplements.


Abortive medications: all triptans but fovatriptan. All of them worked 30=60% with sumatriptan working best. Cafergot helpful but caused nausea.


Also, if you are read to make the assumption that she has rebound headaches . . . well, the other headache clinics have aggressively taken her off all symptomatic medications up to a couple of months with no improvement.


Exam: Normal. She strikes me as a nice lady, who really wants to be better and has no secondary gain issues. She is on disability for her headaches, but she has plenty of money (husband retired executive).


So . . . what would you do?

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food logs etc tried?

Yeah, mentioned above that she had tired diets, supplements and etc. She actually has read almost every headache book out there about food triggers. She did those things about 30 years ago and has tried over and over with food triggers and etc. I've never seen headaches this bad for which food logs helped, maybe others have.

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We saw a lady not unlike this and referred her on eventually. She is an ER physician - so you would think she would do anything to stay out of the ER - but during a particularly bad period last year she insisted upon being admitted. She got IV steroids in hospital which resolved her headache within 24 hours. She eventually improved somewhat with botox but the other protocol she started on was short courses of dexamethasone after 3 days of headache.


Interestingly her husband tells us that she often says "I'm thinking about having a headache"

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I would try Migranal nasal spray or injection.


Oddly, despite being seen at three major headache clinics, she is dihyrdoergotamine naive.


My plan for her was complex (we spent two hours together) and I can't go through the whole thing here. However, the mainstay is starting her on metherigine .2 MG tid for one week and then 2-0.2 MG bid. She has to give up her triptans completely. But for breakthrough headaches she will self-inject dihydroergotamine 1 MG SQ in lieu of one dose of methergine that day.


I am also starting her on a fioricet taper. I would have her substitute one tablet of Fioricet with phenobarbital, however she is already taking 2 MG of clonazepam at HS, so I will have her take 1/2 tablet of clonazepam in place of one dose of fioricet.


I'm also having her read about an inpatient headache treatment program (where I use to work) in Ann Arbor, MI. If she is not making progress, I will send her there. They have about a 60% success rate in patients such as this. I also considered a steroid burst to help turn the corner. I didn't but I might next time.

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