Dr. Robbins describes a patient, Heather, who is a 24 -year -old hairdresser with migraines since age 12, which have been slowly increasing. Her usual  daily headache is an aching, throbbing moderate headache with photophobia. About 6 times per month, Heather has a moderate to severe migraine with nausea and lasting one day. She has been diagnosed with chronic migraine (CM). Triggers for her more severe migraines include weather changes, stress, and menstruation (1 day prior to her menses).

Heather has also struggled with Irritable Bowel Syndrome for much of her life. She has associated neck pain, with tenderness in her neck and shoulder muscles. She clenches and grinds her teeth, particularly at night while sleeping. She was prescribed diazepam, but says, “I became wired and had a bad reaction on it….”

Heather has not been on daily preventives. She consumes four Extra Strength Excedrin daily and, for her migraine, uses hydrocodone. This dampens the pain but does not help any more than 30%.

Heather has also been diagnosed with generalized anxiety disorder and depression. She is chronically irritable and somewhat angry; she has several spells a year which she describes as “too much energy, where I don’t sleep much.” In certain seasons, she seems to cycle into worsening depression.

Heather was place on fluoxetine, and she “was up all night, my mind was going too fast.” She was then prescribed duloxetine, and the same thing happened. Heather also becomes “wired” from certain medications, such as pseudoephedrine.

The question posed to Dr. Robbins is, “Outside of Medication, What Would You Suggest For Heather?

We need to teach Heather about regular sleep habits, not missing meals, avoiding too much caffeine, identifying stresses that may contribute to her headaches, engaging in exercise and improving posture, etc.

In addition, a referral to a good psychotherapist would be beneficial, as would biofeedback by a skilled therapist. Psychiatric referral would be a reasonable choice as well.

To be continued…..