Lawrence Robbins, MD
Individuals suffering from chronic pain often have psychiatric comorbidities. For instance, among those with chronic migraine approximately 9% fit into the bipolar spectrum. (1) This article discusses a representative case of a patient with chronic migraine and bipolar disorder as well as epilepsy and irritable bowel syndrome.
Caitlin is a 28-year-old female who has experienced frequent depressive states since age 14. Caitlin finally was diagnosed at age 26 to be on the mild end of the bipolar spectrum (DSM-5: Other Specified Bipolar and Related Disorder: 296.89). She presents with her depression in remission. She is on quetiapine 50mg and 100mg of lamotrigine, each once per day.
The patient has moderate chronic migraine and describes daily mild to moderate daily headache. She has a moderate migraine twice weekly, and a severe migraine attack once a month. She takes 8 OTC aspirin/acetaminophen/caffeine tablets (Excedrin) daily.
Caitlin reports significant occipital and neck pain. She has had tonic-clonic epilepsy since age 12. Her seizures are infrequent, and since being placed on lamotrigine she has had no further seizures. Caitlin also has moderate irritable bowel syndrome, primarily with diarrhea (IBS-D).
Work-up as negative, including MRI of her brain, routine blood tests (including thyroid), and the neurology examination.
What Additional History May be Helpful?
In this case scenario, relevant factors to consider and further investigate include:
- Frequency and severity of the patient’s headaches
- the past response to medications and family history of response (family history of medication response brings in the “placebo by proxy” and “nocebo by proxy” responses)
- Potential sensitivities or side effects to medications
- Psychiatric comorbidities
- Medical comorbidities
- GI issues (in this case, IBS-D)
- Any complaints related to sleep, fatigue, or insomnia
- The patient’s job requirements, social support, and any financial/insurance concerns that may impact her treatment
- Patient preference for medication (eg, they may not wish to take daily medication, or may request to use natural remedies)
In addition, a history of the specifics of this patient’s depression would be helpful. The details of her moods, hypomanic symptoms, triggers, etc. are important if an adjustment to psychiatric medication is appropriate. (2)
Is the Patient Suffering from Medication Overuse Headache?
It is also worth considering whether the patient may have medication overuse headache (MOH) which is often conflated with medication overuse (MO). Medication overuse is arbitrarily viewed as consuming certain abortive medications (eg. combination analgesics, triptans, opioids, butalbital compounds) at least 11 days per month. If patients simply take NSAIDS, MO is defined as consuming the NSAIDS at least 15 days per month.
A determination of MOH is more complex as it tends to be poorly defined and over-diagnosed. (3) To determine if MOH is present, a careful history has to be taken as to the effect the drug had on the person’s headaches. The drug (in this case, Excedrin) must be withdrawn to see if the headaches improve. Caitlin reports taking 8 Excedrin on a daily basis, each of which contains 65 mg of caffeine. It would be helpful to determine how much additional caffeine she consumes.
We should attempt to limit her caffeine intake to 150 or 200 mg daily. While small amounts of caffeine help many patients, other migraineurs cannot tolerate even minimal amounts.
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