The case history of Heather continues….
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.
For the neck pain, physical therapy may be helpful, at least as far as teaching about exercise and posture. Heather’s profession as a hairdresser often will exacerbate neck pain and her headaches due to the constant arm movements. A dentist who is adept at evaluating temporomandibular disorders (TMD) may be beneficial for Heather as well.
We do not expect Heather to rush off to the psychologist, psychiatrist, physical therapist, and dentist all at once. Because of money and time, most patients carefully select which healthcare professionals they visit. However, it ‘takes a village’ to treat a complicated pain patient and I try to refer the patient to appropriate specialists.
We need think talk about the mild end of the bipolar spectrum. According to one study, 8.6% of migraineurs fit into the bipolar spectrum. Heather has a number of features of bipolar disorder, including early onset depression (age 14) and a family history of depression, spells of too much energy, and poor (bipolar) reaction to certain medications (antidepressants, pseudoephedrine, diazepam). The clinical stakes for missing bipolar disease are enormous. Patients such as Heather tend to bounce from antidepressant to antidepressant, with predictably poor results.
Comorbidities, along with the headache characteristics guide where we go with the headache medications. Along with the chronic daily headaches and migraines, Heather fits the mild end of the bipolar spectrum, has IBS, neck pain, and has struggled with weight gain. All of these characteristics figure into our medication choices.
As a headache preventive, topiramate may be a good choice. It will not cause weight gain and may decrease appetite for some period of time. It may act as a mild mood stabilizer, although studies have reported both positive and negative results on topiramate as a bipolar medication. Topiramate may almost certainly exacerbate depression. We would begin with a low dose because headache patients tend to be somatic and will not tolerate large initial doses – often leading to them quitting the medicine prematurely.
The cognitive side effects of spacey feelings and memory problems often limit topiramate’s use, as does the tingling sensation in fingers and toes. Primarily due to carbonic anhydrase activity, the tingling is sometimes offset via the use of potassium – either natural or in tablets/powder. There is now a longer-acting form, generic topiramate ER.
To be continued….