Headache Challenge: Woman With Worsening Headaches and Depression

THE CASE: The patient is a 48-year-old married woman with 2 grown children. She began to have occasional headaches when she was 7 years old. These occurred with a frequency that ranged from several times a year to monthly.  The patient’s first depressive episode occurred in high school after a date rape. She attempted suicide and was hospitalized for several days. The hospitalization was followed by daily headaches and her first severe migraines. After several months, the headaches gradually subsided. Ten years later, she was hospitalized for a second major depressive episode. Subsequently, she was treated with antidepressants and had a full remission of her depression; however, she continued to have occasional headaches. The headaches were migrainous; they were associated with nausea, vomiting, photophobia, and phonophobia, and they prevented her from functioning. After her second child started high school, the headaches became troublesome. Gradually, they have become more frequent and severe, and she has used increasing amounts of medication. She had recently started to work outside the home, but the severe headaches caused her to leave her job. Although she has not had depressive symptoms for some time, the patient says that she has been unhappy throughout her life because of her difficult childhood. Her mother was an angry woman who frequently beat and deprecated her, her father was critical and disapproving, and the parents favored her 2 older siblings. Because she felt unloved as a child, the patient tries hard to please her husband and children. The patient’s mother remains critical of her. Although the patient’s husband was sympathetic at first, he became upset with her because she gained 40 lb as a result of medications she was taking. She feels betrayed by her husband. The patient has sought treatment because, as her headaches have worsened, her depressive symptoms have become troublesome again. ➤Is there a connection between this patient’s emotional and interpersonal difficulties and her worsening headaches? ➤What is the best way to identify her particular emotional triggers? ➤What management strategy would be most helpful to this woman? Dialogue on next page , THE DIALOGUE:  Primary care doctor: How can I best determine—and address—the cause of this patient’s worsening headaches? Headache specialist: The importance of a thorough headache history cannot be overestimated. In particular, I would ask about the circumstances that surround the onset of a headache. The development of migraine appears to be based on a cascade of events in susceptible persons that probably occurs as a result of many irritating processes that affect the brain and the peripheral nervous system.1-6 Many potential precipitants are easy to recognize. Known triggers include bright sunlight, persistent loud noise, missed meals, alcohol use, food sensitivities, and stress. Primary care doctor: My patient believes that her headaches worsened after a prolonged argument with her husband over his lack of understanding of her problems. He had made remarks that made her feel hurt and unloved. She reluctantly admitted that she was angry with her husband. Headache specialist: Life situations likely to cause stress can be classified into 6 categories: •Domestic. •Financial. •Occupational. •Academic. •Other-relational. •Medical. The stress that arises from a given situation may involve elements from several categories. Often, stressful situations involve relationships that have become unsatisfactory and that make the persons involved feel unsafe or overwhelmed. In general, stress triggers are more difficult to isolate and manage than other types of migraine triggers. They are often unique to a particular patient; that is, a situation that triggers a migraine attack in one patient would not necessarily precipitate a migraine attack in another patient. Primary care doctor: Could I perhaps use the patient’s own analysis here to help her understand her particular personal trigger? Headache specialist: Usually, a counselor or psychotherapist must carefully review the history, focusing on the patient’s responses to events. Once a pattern has been identified, a therapist can help the patient develop more control over emotional arousal and can suggest more effective ways of coping with challenging situations. In addition, a therapist can provide support and validation. Therapy may not change specific behaviors in a stressful life situation, but it can sometimes alter a patient’s internal response to a triggering event. By learning to control her reaction to her husband’s comments, your patient may be able to prevent her headaches. Primary care doctor: I will recommend that my patient enter therapy. I don’t anticipate that therapy will be easy for her, but it would be well worth the effort if it decreased the frequency of her headaches. It would be worthwhile even if the only result were an improvement in her ability to cope with her husband! Is there any particular type of psychotherapy that is more effective in helping patients manage migraine triggers? Headache specialist: The type of psychotherapy (eg, cognitive or interpersonal) may have little bearing on the practitioner’s success in “extinguishing” a trigger. Sometimes, guiding a patient in stress management techniques may be the most effective approach. REFERENCES: 1. Shulman BH. Psychological factors affecting migraine. Clin J Pain. 1989;5:23-28. 2. Adler CS, Adler SM. Psychodynamics of migraine. In: Adler CS, Adler SM, Packard RD, eds. Psychiatric Aspects of Headache. Baltimore: Williams & Wilkins; 1987. 3. Grzesiak RC, Ciccone DS. Psychological Vulnerability to Chronic Pain. New York: Springer; 1994. 4. Diamond S, Dalessio DG. The Practicing Physician’s Approach to Headache. 6th ed. Baltimore: Williams & Wilkins; 1999. 5. Marcus DA. Chronic headache: the importance of trigger identification. Headache Pain. 2003;14:139-144. 6. Martin PR. How do trigger factors acquire the capacity to precipitate headaches? Behav Res Ther. 2001;39:545-554.