Migraine Case Study
Britt Talley Daniel MD
Case study #1
A twenty-five year old single woman presented with the chief complaint of “daily headaches for the past 30 days.” She has a previous history of allergies and depression and currently is on treatment with Zoloft. She had a progesterone implant in her arm for contraception. She started having migraines at 12 years old at the same time she started her menstrual cycles (menarche). She reports that the time her usual migraine lasts is 7 days. Using the International Classification of Headache Disorders (ICHD) check list for diagnosing migraine she had all the features of migraine without aura except nausea.
The ICHD check list is:
Migraine without aura
- At least 5 attacks fulfilling criteria B-D
- Headache attacks last 4-72 hours (treated or untreated)
- Headache has at least 2 of the following 4 characteristics:
- Unilateral, one sided, hemicrania, half of head
- Throbbing, pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity
- During headache at least one of the following:
- Nausea and/or vomiting
- Photophobia and phonophobia
Her usual headaches are level 7-10 and usually right-sided and throbbing. ICHD states that migraine headaches may be 5-10 while the other frequent type of headache, tension type headache, can only go from 1-5 and is a mild or moderate headache, while migraine headaches may be severe. Many patients answer “20” when asked to rate headache on a scale of 1-10. This patient carries chronic tension in her neck and shoulders which is a feature of generalized anxiety disorder (GAD.)
Neurochemicals are released by ganglia in the brain during a migraine and these chemicals are inflammatory, like applying acid to the back of your hand, and cause dilatation of the cerebral arteries. When blood from the heart pulses through this inflamed and dilated artery, it cause the artery to stretch and that hurts, resulting in a “throbbing or pulsating” headache. According to ICHD tension type headache is described as “pressure or tight” and is a bland, featureless headache.
Migraine headaches are usually one sided and come from the word hemicrania, an early term for migraine dating back to the Roman physician Galen in 235. Taking off the letters ‘he’ from hemicrania leaves the word ‘micrania’ from which migraine comes. There is no known reason why migraine headaches are one sided but it is a secure clinical feature. Many patients say that their headaches are always “side locked” to just one side rather than switching sides, coming on the right side most of the time but occassionaly coming on the left. Considering organic or “serious” symptoms of headache, a headache that switches from side to side is just what migraine does, but a diseased artery with an aneurysm or arteriovenous malformation may always give the same one sided headache. So, a migraine headache that switches from side to side is a reassuring and benign feature.
She also has menstrual headaches (defined as a migraine that starts the day of bleeding with the menstrual cycle or two days before bleeding or two days after starting to bleed), nocturnal headaches, and wake up headaches. Most all menstrual headaches relate to migraine and menstrual headaches start 3 weeks into the usual 30 day cycle when bleeding occurs and the internal estrogen level drops.
Nocturnal headache has a wide differential diagnosis of other headache causes including subarachnoid hemorrhage from intracerebral aneurysmal rupture, temporal arteritis, cluster headache, hypnic headache, or a brain tumor. However, the most frequent cause of nocturnal headache is migraine.
The neurochemicals that come out during migraine make the patient very sensitive to movement or being up, so the typical patient wants to lie down quietly or try to go to sleep, which will sometimes result in the patient awakening several hours later feeling better. Cluster type headache patients have to be up and moving and they may pace around the room.
The human brain has a trigger zone for nausea and vomiting in the upper medulla which maybe turned on by the migraine process. This is why migraine may be called “sick headache.”
The migraine process inflames and irritates the sensory cranial nerves and so hearing, carried by the eighth acoustic nerve may be inflamed so that mild noises are felt in the head as painful and the patient has “sonophobia.” Likewise the retinal neurons in the eye are inflamed so that light coming into the eye is painful and the patient reflexly closes his eyes and has “photophobia.”
ICHD doesn’t list allergy as a causation of headache so there really is no “allergic headache.” But depression is linked to migraine about 50% of the time along with generalized anxiety disorder (GAD) 34 % of the time. The case study we started with had a history of depression and menstrual headache. These may be called migraine “links” which are associated features of migraine that alone are not diagnostic but with a positive ICHD check list present a comprehensive view the the totality of the migraine syndrome.
During sleep there are usually 3 or 4 dream events spread out through the night during which time the eyes rapidly move and this feature can easily be detected during an EEG, electroencephalogram, by recording electrodes places near the eyes. During dreaming the internal autonomic system turns on and the cerebral arteries go into vasospasm, which then is released at the end of the dream state so that the patient may “wake up at the end of a dream” with a bad migraine. These come deep in the night or many times about 2 hours after wakening in the morning. For a person who went to sleep at 11 p.m. and usually awakens at 7 a.m., the last dream event may come at 5:30 a.m. The problem is that many patients don’t wake up at the start of the migraine and are not able to treat early, like with one of the triptan drugs which should be taken early in the migaine process. Sleep continues and the migraine process goes on, the chemicals are released, and then the patient has a severe “wake up” headache which is hard to treat. This patient started with a wake up headache 30 days before I saw her. Such a headache may start a process of taking too much medication which then keeps the headaches coming.
The patient also mentioned that her usual migraine lasted 7 days. This amount of time is not consistent with the ICHD concept which gives a strict time duration for an episode of migraine that can only last 4-72 hours. So, an episode of migraine could last 3 days but not 7 days. This patient had already had a normal CAT scan of sinuses and MRI brain scan when I met her and she had a normal neurologic exam. With these reassuring features I could be very certain that she was over treating with analgeics and getting medication overuse headache and likely short term chronic migraine (defined as 15 headache days a month, 8 of which have migraine features.) On close inquiry she admitted to the following medications which she rotated:
Tylenol (acetaminophen) 500 mg for the past 2 weeks every day 2-3 tabs
Fioricett (acetaminophen, caffeine, butalbital) the past 3 days 2/day
Sumatriptan 100 mg for the past 3 days 1/day
Tramadol for 2 days 1/day
Only 3-4 percent of the world population get medication overuse headache although the incidence of migraine peaks in women at age 42 so that 25% of women have migraine at that age. Not all migraine patients get medication overuse headache and it may be a special genetic feature of certain migraine patients which hasn’t been defined yet. In general migraine patients should limit caffeine and over the counters and triptans and narcotics to no more than 2 days a week and they will probably stay free of medication overuse headache.
Read my handout on the webpage about the migraine lifestyle and medication overuse headache to get up to date with those subjects. The day I saw this patient I advised her to stop all painkillers, triptans, and narcotics (tramadol, Fioricet). I asked her to do the migraine lifestyle, start a preventive drug, amitriptyline 10 mg at night, to continue her Zoloft, to take a week of prednisone 20 mg three times a day for 7 days, and to use Migranol generic DHE nasal spray 2-4 sniffs as needed every 4 to 6 hours. I asked her to call me for problems and to return to clinic in 7 days. Hopefully she will do well.