Skip to main content

34-year-old female presents with chronic migraine

History of present illness: The 34-year-old patient reports feeling overwhelmed lately, and notes that according to her headache journal, she spends over seventeen days each month with migraines. She was diagnosed with chronic migraines over nine years ago, reporting that they have gotten worse with time. In the last year, she has put on thirty pounds because her migraines are so bad, she suffers from anxiety and depression. She reports feeling like she cannot exercise, socialize, or date, and while she is lucky to have a very understanding office, she is concerned that she is overstaying her welcome because she feels like such a burden. She currently takes Imitrex for flare-ups, but feels like nothing actually helps the headaches, having tried "every FDA-approved medication available." She reports experiencing some double-vision and tinnitus lately.

Social history: Patient denies illicit drug, alcohol, and tobacco use. She lives with her parents who help take care of her. 

Medication: Imitrex. Ondansetron.

Allergies: None.

1. Do you suspect this patient of having any comorbidities? If so, how should they be diagnosed and treated?

2. What upcoming treatments (if any) would you counsel this patient on? 

  • from Generation NP 4 weeks 1 day
    I would review her records and see what work up she has had in the past with an update on her labs and make sure her thyroid function is ok. Ask about depression and other issues. She may benefit from Topamax to prevent her headaches and this may also help her lose weight. Would consider CGRP for acute treatment.
  • 1 month
    I think the 50% benchmark is there because that is what is used in studies to be considered a successful trial. I understand that people do not have headaches at birth but migraines are genetic and so there are people who are more likely to suffer from them than others even in the setting of the same triggers.
  • 1 month

    There are many very good ideas here that I agree with, however, I would caution against a couple of things that people suggested though we all know that approaches are never necessarily "wrong" but sometimes paths taken to the right answer may be much longer and unnecessary things done that do not benefit the patient or less benefit the patient. For example, CT of the head was mentioned but I'm not sure what that would show in a patient with CHRONIC headaches for 9 years who is NONFOCAL neurologically (WE ASSUME). Deterioration of her condition is not anything significantly organic so far as the history is concerned except headaches are getting more difficult to tolerate and unresponsive. Remember, CT scans emit up to 200x more radiation than plain X-rays and from a neurological point of view are less useful than MRI imaging in someone like this who could very well have an as of yet undiagnosed condition of IIH though we are still missing some more typical features such as visual obscurations which are typically much more dramatic and easily described by patients suffering with IIH other than double vision.....Nevertheless, I don't think an MRI of the head would be a bad move if imaging were to be considered as part of her workup. Of course, most people of her status (chronic worsening 9 years of headache) will have likely had an imaging study in the past 12-24 months and so I always check on that first to see if maybe all we need to do is REREAD a prior study and even compare it to ANOTHER study which may have been study several years before that looking for the slitlike ventricles, sulcal effacements, etc.

    Second comment I would make about a comment stating (and I'm paraphrasing here)... "if BOTOX AND CGRP inhibitors are proven negative....then, address lifestyle changes." In our headache clinic we teach our residents to think exactly the opposite.....headache diaries are particularly useful (if patients are taught how to properly document) in demonstrating LIFESTYLES and BEHAVIORS which they should be recruited into believing can have huge impacts on headaches...ALL TYPES of headaches. In fact, the #1 TRIGGER for MIGRAINE (indeed virtually all types of "stimulatable" headaches) turns out to be STRESS of a psychological nature. And in this woman I entirely agree that depression, anxiety, self image are all very large and looming risk factors if not TRIGGERS to a large % of her headaches. I would be more rapid to be addressing these issues BEFORE adding more drugs that are incredibly expensive, difficult to get approved through insurance, and may be poorly effective IF THE OTHER SIGNIFICANTLY COMORBID and possibly unaddressed issues of lifestyle and psyche have not been looked into. I offer these patients other complementary forms of treatments which have a large rate of success and can be used frequently without risk of causing REBOUND such as DEEP BREATHING EXERCISES, THERMAZONE DEVICE (excellent device created by a NEUROSURGEON who suffered from frequent migraines), and of course, has been mentioned getting her on a definitive program of EXERCISE AND DIETARY THERAPY.

    Comment was made on working her up for a malignancy but no mention was made of which one exactly that could be responsible for this person's 9 year history without anything significantly malfunctioning in terms of other organ systems or more classic signs of malignancy after so much time such as weight loss, loss of appetite, metastatic complications that could result in unrelenting bony pain, abdominal pain that is unremitting usually resulting in GI interventions which she's at least not revealed to us through history. So again, I don't know that would be as high on my list of things to rule out at this point as other things.

    I am almost certain this lady is an excellent candidate for MEDICATION OVERUSE (MOH) simply based upon my experience that unfortunately, many providers even lay the groundwork for that complication by telling patients to use TYLENOL up to label instructions so that they "always have a steady amount in their system"......that only adds fuel to the flames. And how many times have I heard patients tell me that their doctors have told them to take their Imitrex as often as necessary.....Actual manufacturer's recommendations on max. usage of the triptans is 2 CYCLES weekly.....AND there is this little known phenomenon which can amplify the efficacy of triptans involving TIMING THEIR USE against the start and evolution of the headache. Taking a 2nd dose at 2 hrs. post initial symptoms is TOO's what the monographs all say, it's what I've heard many headache specialists even agree to....but there is a BETTER way to implement triptans which can amplify and improve efficacy in at least 20-30% of patients who tolerate and are considered good candidates..... Could she be suffering from just a bit of poor timing with this drug combined with taking too much of it and her OTC's which we don't know about but I'll bet she's using.

    Also, how many really promote the INJECTABLE form of sumatriptan (Imitrex) as much as we really should? It's the fastest acting form of any triptan available and most efficacious when the timing protocol is utilized to optimize its effects being far superior to any of the oral forms of the drug. Where patients take oral doses of sumatriptan and get virtually no relief at hundreds of milligrams daily other patients taught the proper way of using the injectable may show relief on the order of 30-50% more frequently according to the statistics from our clinic. And it's not as hard to convince to have patients inject themselves when the reward is killing their headaches in 60 min. or less or 2 hrs. at the outside if 2 injections are used (which they can be).

    And there are other things to do with this patient that I would do if I were directing her care.....which would likely involve the same approach we are all familiar with in an ICU or NSU patient who develops a FEVER OF UNKNOWN ORIGIN (FUO) who has not been responding to anything we give them in terms of antibiotics, antipyretics, hydration, and of course, NO SITE of obvious infection (even with sophisticated WBC radionuclide labeling, etc.). What do we do in those patients who are constantly getting multiple blood cultures, induced sputums, and US's of every crevice in their body and head?

    WE STOP EVERYTHING, let the patient WASH out of all the mud we've created in their system.....and we start over....this time, we build slowly, and whatever we choose to order or recommend....comes with a very good and provable reason or circumstance. Then, USUALLY the FUO resolves and we never really figure out what's going on....except to say somehow the patient got better when we stopped "monkeying" around so much with their system using more and more drugs and tests and let things just go amok based on our urgent need to bring the fever down as opposed to treating the patient.

    The SAME THING in this patient (which I do constantly in our tertiary Headache clinic) and that is to start from the very beginning, "a very good place to start" sings Julie Andrews.....And I teach the patient about a headache diary...give them my own...not some APP from Google or Playstore....junk all of them.....I give the patient MY DIARY PARAMETERS because I know those are the things I know very well how to read when looking for headaches (diagnoses) as well as what to look for in order to gauge AS SCIENTIFICALLY AS POSSIBLE) if a treatment is working or not......

    BTW, someone else made a comment about reducing headaches by 50% as being a measure of GOAL which is ongoing in my patients is to get them to 0% in their headache frequencies, intensities, and numbers of symptoms, 0 headache days/week/month, and to try very hard to find the way to GUIDE THEM BACK to a state of INTRACRANIAL HOMEOSTASIS that they used to enjoy.

    Think about it...assuming there is no architectural abnormality present at birth that can lead to chronic and debilitating migraines and there are no hormonal or endocrine problems responsible since all those things comprise the great MINORITY of etiologies.....are people BORN with headaches? Not so far as I've ever read in the literature.....and in fact, most of my patients clearly make it beyond their teens without headaches at all......THEN, SOMETHING seems to change.......that's the point I start interviewing patients and having them really try and tease out events, happenings, traumatic injuries to the head that they'd forgotten about, very bad and horrible family circumstances that involved abuse to the child while growing up that they've never wished or even forgotten about so nobody finds out.....but that only comes through digging as deeply as possible....and of course, we dig into genetics and follow up those leads as well.

    In conclusion, this patient I believe is a great example of an individual who on the one hand could be easily classified as COMPLEX and DIFFICULT since she comes with such an exhaustive history of failure "to every medication" known to man. But on the other hand, is she so complicated or is she perhaps VERY SIMPLE? Might she not be much simpler than we think she is.....if we just stop "monkeying" around with more and more drugs, more and more tests, and remember that she likely once lived a normal painless life when she was HEADACHE AND SYMPTOM free....I'll bet anyone credits to navy beans that if any one of her doctors ever did ask her about such an existence, that the answer got buried in the notes, if it was even written at all. We need to keep our eye on the ball which is to drive and help GUIDE her back to that state of affairs of being HEADACHE FREE using the tools we are expert in using to the most minimal degree necessary to bring her headaches under GREAT CONTROL and then, to rely and work with passionate colleagues who also have expertise to help her discover why and/or how things CHANGED which took her down a path that somehow became that of CHRONIC UNREMITTING headaches.

  • from Generation NP 1 month
    Yes, she definitely needs worked up for comorbid conditions and treated. I would consider a head CT to rule out intracranial etiology & also start migraine prophylaxis RX. Topamax could be an option, which may help with weight loss.
  • from Doctor Unite 1 month
    She says she has gained 30 pounds. I am assuming she may be obese and may be suffering from idiopathic intracranial hypertension which may also be causing her double vision and tinnitus. Check her BP and treat with diuretic. Again anti-CGRP such as Emgality. Aimovig contraindicated in patients with hypertension. Weight loss.
  • from Doctor Unite 1 month
    Concomitant conditions must be investigated
    A CGRP might help
  • from Doctor Unite 1 month
    Yes, she needs a work up for comorbid conditions. However, she needs to be on some type of migraine prophylaxis. Her prior medication history would be my guide for the choice.
  • from Doctor Unite 1 month
    Malignancy work up. Treatment of depression. R/o sleep apnea. Daily preventative
  • from Doctor Unite 1 month
    Based on her symptoms of double vision, tinnitus, and taking anti-emetic I would do a full work up to rule out any malignancies. Her migraines are causing her to have a low quality of life and preventing her from doing normal activities. I would prescribe her medication to prevent migraine episodes such as emgality.
  • from PA Unite 1 month
    She could have obstructive sleep apnea. I would order a sleep study to rule out OSA and treat it with CPAP if tested positive. Weight management, as well as addressing her anxiety and depression may help her migraine management.
  • 1 month
    I would need a more detailed history of medications tried as well as confirmation that her exam including funduscopic exam was normal. There are many medications used for migraine prevention that are not FDA approved. I agree with Dr. Sheikh that she clearly sounds depressed so if she has not tried venlafaxine, it might be helpful with mood and sleep (although is unlikely to improve her migraines by 50% which is the goal). It is important to insure that she is not in medication overuse which is quite common with chronic migraine. Lastly, if she really has tried 5-7 preventive treatments, including Botox and a CGRP mab, I find that lifestyle issues and behavioral approaches need to be addressed. I make the following recommendations to patients:1. Sleep: follow the same sleep routine every day (even weekends), getting 7-8 hours of sleep per night, avoiding screen time for at least 2 hours before bed, consider melatonin if issues of falling asleep
    2. Nutrition: eat at least every 3-4 hours while awake, choose healthy simple foods and avoid fast foods or junk foods
    3. Hydration: Drink at least 48-60 oz of water per day. Avoid sodas (even sugar free) , juices with high sugar content and energy drinks
    4. Caffeine: No more than 8 oz in the am before noon
    5. Exercise: At least 20-30 minutes of low impact exercise (such as walking) at least 3-4 days per week
    6. Stress: Build in time every day for self care which can be walking, reading, journaling or some other hobby. Meditation and mindfulness can be quite helpful. Cognitive behavioral therapy has been shown to be helpful with migraine
  • 1 month
    She herself notes having depression and anxiety which should be addressed. She may also have obesity that can be a condition to transfer someone from episodic to chronic migraine. She would be a candidate for botox or the cGRP inhibitors unless she is planning pregnancy anytime soon.