Pain Management

Battling Migraines

I am writing this down, for the same reasons people have written stuff down from the beginning of written language, so I don't forget. If I wrote it down on a physical piece of paper, I'd just loose it, this way its out there, but at least in a there I can find it. :)

Stacey gets migraines. This past weekend she could feel one coming on. Here is how it progressed. Saturday I took Miles out with me to I took Miles out the Middle Fork, while Sofi and Kiah went to ask out Christian Rennie to Girls Choice Dance for Kiah's first date just after her 16th birthday. Stac took a phenergran suppository Saturday evening to get rid of nausea, help her sleep and hopefully the pain would subside. Sunday the pain continued and she stayed home from Church, with the headache getting progressively worse. By Sunday evening she was throwing up and the pain had got to a 8 or 9 on a 10 point pain threshold and so we did what we always do : go to the Emergency Room.

The Emergency Room's response is to give her an anti-nausea medicine, usually phenergran suppository or zofran combined with a heavy narcotic like dilaudid or demerol. This numbs the pain and knocks her out, causing her to be very drowsy, sleepy. Unfortunately the narcotics are in such high doses she is out of it for 24-48 hours. We went home Sunday night, but at home the headache came back, she threw up again during the night several times. Monday I stayed home from work, and she made an appointment to go see Dr. William Kinnish her primary care physician. While in his office she ended up throwing up again. Since his office is adjacent to the Emergency Room he sent her back to the ER. I joined Stacey there, where they went through the routine of administering the same medicines along with an IV to hydrate her. After a couple of hours they sent her home, where unfortunately the headache returned as did the nausea, she threw up several times through the night. Tuesday morning she threw up several more times, but the nausea finally stopped and her headache gradually subsided.

Stac has had migraines for over 10 years. She used to get them in California and we traveled to UC Davis to see a neurologist and had the gamut of tests to rule out brain tumors and other causes. He had diagnosed her with tension headaches, which never really seemed identify a cause. When we moved to Seattle she started seeing a neurologist in Seattle, Dr. Sheena Aurora. Stac had a series of migraines last year from March through summer, but hadn't had one since last August. I put calls into Dr. Aurora's nurse triage line all day Tuesday, and got a call back in the late afternoon from the nurse who said she'd have Dr. Aurora call Wednesday morning. Wednesday morning Dr. Aurora called and Stac made an appointment to go see her in the morning, I accompanied her to try to get answers and a better understanding.

Its always nice to meet professionals who are the top in their field. Dr. Keenan was one of these, you could just tell she was top notch and she specialized in headaches. She explained the following :

A migraine is a headache with severity that it interrupts daily life activities. For Stacey at their peak they involve intense pain, throbbing and often nausea. They often correlate with her menstrual cycle. They can be trigged by tension, and or stress. Additional contributing factors can be high blood pressure. Stac's family has a history of high blood pressure, and she has been treated with high blood pressure medication. Migraines are caused by neurological and inflammatory response in nerves in the brain, sometimes called an excitability factor. The problem with narcotics is that they shut off the receptors, they numb, but the headache remains you just don't know it. Not only this but they are just physically numbing, staying in your system for days and they can have rebound properties where the headache and pain rebounds. There is however a drug specifically designed to stop the migraine process : DHE or Dihydroergotamine. There are two methods of intake, intravenously or subcutaneously via an injection. There is also a nasal version known as migranal, though its not as effective in its delivery. There is also a drug called topomax which is a neuro modulator and can decrease the excitability that leads to migraine conditions.

So our plan of attack for headaches going forward is :

• Get Stac regular massages to reduce tension
  
• Start Stac on topomax

If she feels a headache coming on

• Take a dose of migranal on day one
• If they headache continues the next day or blows up to a migraine then she should during office hours call the pain clinic and one of Dr. Aurora's nurses will administer the same day a dose of DHE and something for nausea
  
• Once we have demonstrated the effectiveness of this, Stac can self-administer DHE via an injection at home

So basically the ER is the last resort, only in the case of after office hours and even then we should have them inject DHE not narcotics.

Before we left Dr. Aurora talked about how she had been trying to change the world for 15 years, but had failed to reach primary care physicians. They don't care. Some of this has to do with the fact that headaches are very common ailment in our society and are often overlooked. Migraines are a special form of debilitating headache. Much of physicians apathy is not intentionally, they just have so many other issues to deal with, colds, weight, flu etc. And its so much easier to just write a prescription for a narcotic. However Dr. Aurora has found great effect by leveraging patients educating their employers and health care plans, because individuals with migraines understand their impact and can lobby to employers and health care providers to pay for treatments that prevent. For example she recently spoke at Starbucks to lobby the human resources to have Aetna for individual overrides to pay for botox injections as these have been shown to also prevent migraines. I think I'll try to set something up at Amazon.

It was good to go visit with a real specialist with deep knowledge in her field. I feel like I have much more educated understanding, and we have a plan. And with a plan we can attack the pain and maybe win a battle or two.