Chronic Migraine – GPs’ and Neurologists’ Different Approaches to Treatment

Not all prophylactic medications work for all migraine patients, and it can take some time to find the right one. Took me 13 years.
 
GPs know squat about treating migraines; they really are only allowed to go through a standard long list of prophylactics, which may or may not work. Typically, you are titrated up to a therapeutic dose and then kept on it for a minimum of three months. If by that time it hasn’t helped, they titrate you back down and move on to the next one. Common drugs prescribed by GPs include propanolol, amitriptyline, topiramate and dosulepine
 
If you’ve been seen by a neurologist who specializes in migraine, he and your GP can work together and try a larger variety of prophylactic meds on you. GPs are only allowed to prescribe a limited number of types of migraine meds because it’s technically outside their specialty. The neurologist can authorize the use of different meds or treatments, such as Tegretol, VerapamilBotox or sodium valproate – the drug I have been on since 2012  – You don’t get near any of those unless your migraines haven’t responded to the list of meds that your GP has already tried on you. 
 
Estrogen can be a very common migraine trigger, so if you have them frequently it might be worth switching to a progesterone-only pill (POP). They try to stay away from estrogen pills for migraine patients, but a GP might not pick up on that – a contraceptive specialist nurse, however, would.
 
Although my periods were never a migraine trigger, I’m on the POP because my periods were always extremely painful.

LINKS

More information on Botox for chronic migraine in adultsThe Migraine Trust
Botox Treatment for Chronic Migraine – Salford Royal Hospital NHS Trust*

*Salford Royal is where I get my Botox done every 12 weeks, done by a specialist nurse, Siobhan Jones, under the care of Mr Adam Zermansky, consultant neurologist. Nurse Jones might be able to direct you to an NHS Trust in your area that offers Botox as a treatment option. 

Has positivity in chronic illness gone into overdrive?

This article in the Globe and Mail talks about how often people with a chronic illness are expected to put on a happy face while being mindful and positive about their illnesses even on their worst days.

Just reading that makes me tired already.

A person with a chronic illness or serious disease on their plates has better things to do than be inspiring and constantly cheerful for other people. It sucks sometimes, being sick, on all kinds of medications that have debilitating side effects, and to put the onus on the patient to keep up happy appearances in spite of what they’re going through is not fair to them.

Your feelings are valid.

You are allowed to complain.

In fact, a patient who does not complain can actually make diagnosis and treatment more difficult for their doctors. If you don’t like to say how bad you are feeling, they may never know if a particular treatment is having any effect at all. If you’re super-creepy-happy all the time, there’s no way to tell when you’re having a day/week when the medication may not be helping you. 

You are allowed to cry.

You are allowed to feel hopeless.

You don’t have to be grateful, mindful, etc, unless you want to.

You do not have to lie to yourself OR others about how you feel.

“In Russia, negative emotions are to be expected, Ryder says. There, having a full range of emotions is considered authentic or realistic, he says, noting that it can sometimes be difficult to detect depression in Russians because it’s accepted as part of life that people experience tough times.
When faced with adversity, “I think they even say, sometimes explicitly, ‘We don’t have to be [like] Americans and smile about it,’ ” he says. “So if you have a death sentence or you’re now going to have to live with a permanent disability, then you would be sort of failing to be in touch with the truth of the situation unless you felt really bad about it.”
…To coax patients to look on the bright side can be extremely unempathetic and can result in a kind of victim blaming, in which a relapse of illness or inability to recover may be seen as a consequence of not trying hard enough to overcome it, says Zaretsky, the psychiatrist at Sunnybrook.”
 
What optimism and psychological therapies can do is improve the quality of one’s life – at least for some people, she says – but there’s no evidence that it prolongs it. [emphasis mine]
 
And even if there were evidence to support the idea that people could fight disease by boosting their immune system through reducing stress, trying to be positive, for some, may itself be stressful, Li says.
 
“If the mechanism is that stress reduction works through your immune system to help you, it’s not going to work if you have to work that hard at being positive,” she says.
So much in this article is right on the nose.

Thoughts on craniosacral “therapy” and osteopathy

Skeptical OB posted about how infants can and do die when craniosacral “therapy” is performed on them. Usually, it’s performed because the parent believes it will reduce colic, or some other normal baby behaviour, and the parent has drunk the kool-aid.

I don’t think a chiropractor has any place treating babies or children, because of how easily the practice can harm or even kill them.

I have had positive results from a trained ostepathic massage therapist. But then, I’m a fully-grown adult. There are, however, some things that he practices that we both know he will never try on me for medical reasons.

For a few months last year, I received massage therapy for my migraines, weekly, from a trained and registered UK osteopath. He was given a detailed medical history, which included my cerebral palsy (spastic) and hydrocephalus (2 shunts in situ). My husband got massages for his hypermobility and fibromyalgia. Hubby was also able to be given certain types of manipulations, which seemed to help and that hubby thought would be safe and useful for him. Both of us are very anti-woo.

He did not do any manipulations on me precisely because of the hydrocephalus, and completely agreed that it was ludicrous and extremely dangerous to do so.

Anyone who has neurological/neurosurgical stuff in their medical histories should think VERY carefully before consenting to any kind of chiropractic manipulations, because given the right set of circumstances, they can kill you. It is imperative that any practitioner you seek treatment from be given your complete medical history. 

Case in point: Since I have shunts in place, no manipulations for me, ever.

He did, however, do occipital release on me, which involves gentle but firm pressure (to your tolerance level) applied at the base of the skull, with the aim of drawing apart those very tense muscle fibers with your fingers in gentle massage. No quick jerks or movements are involved, as may be present in a chiropractor’s repertoire. I can do it on myself sitting up, but it was more effective when applied with me laying on my stomach. He also worked extensively on my back an neck muscles, because they are a very common source of tension, which can in turn cause migraines.

Later on, when I began receiving Botox for migraines on the NHS, we learned that some of the injection sites are the back of the neck, the trapezius (shoulder muscles), and the base of the skull – all of which are the same areas of muscles that massage targets.

Unfortunately, the osteopath has since moved away, and we’re still looking for a replacement that can handle my case, as well as the difficulties I have getting onto and off of those tables the patients lie on. I really felt an improvement after months of hard work on my muscles. CP is a permanent disability, and being spastic in my case means my muscles are tense a lot of the time, especially when I’m doing anything other than lying down. I still have the chronic migraines, and I’m still getting Botox, but that osteopath did some really good work for me.

If I ever find a new one, we’ll have to start all over again because I’ve tensed up over time again.

***** Please note: I am not a health care provider or medical professional, so none of the information on my website should take the place of consulting a medical professional. Do not try these exercises without first consulting one. *****

June is Hydrocephalus Awareness Month

This is what it looks like to have hydrocephalus or chronic migraine.

Just because we are “good” one day does not mean we are “good” the next… and just because we had surgery we are not “fixed”. Shunting is a management system for us. It helps and for a lot of people it works wonders for years but other times they fail, and clog and get infected some times all of the above and some times finding the proper balance of fluid flow is next to impossible leaving some with chronic pain and other problems.

Some people with hydrocephalus need very few shunt revisions (surgeries) in their lifetime, whilst others require more frequent revisions, or adjustment of settings on the programmable types of shunt.

Hubby and I are convinced that my repeated revisions (completely justified and necessary at the time) were partly responsible for my severe form of migraine today. Scarring left from the surgeries, plus congenital brain damage, plus a lower set point (threshhold) for migraine triggers to begin with.

Example: Practically anyone, given the right set of triggers or conditions, can be made to have tonic-clonic (grand mal) seizures: the most recognizable form of epilepsy. But not everyone has epilepsy because their brains can tolerate the stimuli that gets tossed at it without the neurons going haywire. In an epileptic person, the brain gets triggered much more easily and frequently (and sometimes we don’t know what the trigger is; it can take a long time to weed anything out).

Similarly, migraine affects millions of people worldwide, but like epilepsy, it has varying degrees of both its severity and what it will take to set a migraine off. For most people, their triggers can either be identified and avoided, and/or medicated easily. For others, like me, medicating successfully has taken a much longer time.

In my case, there are almost no triggers we can clearly identify. The ones we have are Camembert cheese (so I haven’t eaten it since 2000), and barometric weather changes (good luck avoiding that trigger!). Medicating by trial and error since this all began in 2003, has been a roller coaster and an exercise in developing patience. (In the event you run out of patience, apply cats, dogs, chocolate, and a loved one’s cuddles.)

So, in a rather roundabout way, this is my story in connection with Hydrocephalus Awareness.

Thanks for reading!

More on Inspiration Porn

There are no ugly questions except those clothed in condescension.

~John Steinbeck

I came across this article today about inspiration porn. I’ve written about it before.

The author, Dana S. Dunn, is currently Professor of Psychology and Director of the Learning in Common (LinC) Curriculum at Moravian College, Pennsylvania. One of his former students has muscular dystrophy,  and has experienced the well-meaning but clueless interactions with other people that leave many of us with disabilities feeling like we’re being objectified, to somehow edify other people by performing the daily, mundane tasks that everyone does.

My former student isn’t the only disabled person who gets comments like these. Lots of people with disabilities get them all the time. Is there a problem? I think so. On the one hand, these casual observers are well-intentioned and just trying to be nice. On the other hand, however, they are treating disability as something extraordinary, like something that must be overcome each and every day (“You must be a hero in order to deal with that all the time!”). Of course, this sort of treatment is also condescending.

What many members of the general public fail to realize is that people’s disabilities are a fact of their lives, personal qualities, and very much a part of who they are. In other words, disability is familiar and part of their identities—its presence doesn’t make them particularly heroic, just as it doesn’t mean that their lives are a constant struggle, either. Disabled persons tend to focus on their disabilities only when they encounter social or environmental barriers, like overly curious onlookers or inaccessible buildings—both of which impede their progress.

Why yes, Mr Drury, I will gladly edify you as I buy weekly groceries.

What I like best about doing my day-to-day activities is that few people notice me, and even better, in the local Costa coffee shop, the baristas don’t treat me any differently from other customers, except to always carry my tray for me to a table (because mobility scooters and a tray holding a hot beverage is a recipe for disaster!). At home, we use travel mugs.

In fact, as I type this, I am considering a second cup of coffee – with a lid on it.

Myth and Reality in “House M.D.”

Everybody lies…even the producers of the hit series House MD.

Dr Gregory House, like his namesake, Sherlock Holmes, is “addicted” to Vicodin. But not without cause: he has legitimate severe, chronic pain in his leg from an infarction that has left him permanently lame. They do not differentiate, in this series, between “addiction” (they love the idea) and legitimate dependence (they eschew it at all costs, even though it is the correct term).

According to author Andrew Holtz in his book “The Medical Science of House M.D.”, The series went from good, in addressing the reality of his pain, to not differentiating between medical need of opiates/pain relief, appropriateness of therapy (i.e. popping Vicodin that never seemed to work), and downright dismissing his pain altogether and labelling him an addict (ditch the Vicodin altogether and go into rehab).

What about the actual pain in his leg? It’s all in his head, right?

WRONG!

This is a second book on the series, by the same author. I wonder if it is as good? Reviews say it only addresses seasons 1-6.

 

Here’s what Wikipedia has to say about poor, weak Vicodin:

Proposed US Ban on Vicodin

On June 30, 2009, a U.S. Food and Drug Administration (FDA) advisory panel voted by a narrow margin to advise the FDA to remove Vicodin and another painkiller Percocet from the market because of “a high likelihood of overdose from prescription narcotics and acetaminophen products”. The panel cited concerns of liver damage from their acetaminophen component, which is also the main ingredient in commonly used nonprescription drugs such as Tylenol. Each year, acetaminophen overdose is linked to about 400 deaths and 42,000 hospitalizations.

In January 2011, the U.S. Food and Drug Administration asked manufacturers of prescription combination products that contain acetaminophen to limit the amount of acetaminophen to no more than 325 milligrams (mg) in each tablet or capsule. Manufacturers will have three years to limit the amount of acetaminophen in their prescription drug products to 325 mg per dosage unit. The FDA also is requiring manufacturers to update labels of all prescription combination acetaminophen products to warn of the potential risk for severe liver injury.

Pharmacodynamics

The half-life of hydrocodone is approximately 3.8 hrs. Paracetamol, the other component, has a varying half-life of between 1 and 4 hours.

So, the main problem:

The drug House takes wears off too often and too quickly for the severe chronic pain he’s got (infarction and muscle death), He would be more appropriately treated with a nerve block or a slow-release form of morphine or fentanyl. But the show’s creators and producers were more concerned with the show than they were with medical facts and the Hippocratic Oath.

 

Medical Update: June 2012

A little about my medical situation…

My doctor (GP) OKed me coming off morphine (last dose was yesterday, 19 June) because we both feel they were making my headaches (medication-resistant migraines) much worse. The headaches have gotten more frequent, not unexpectedly, and much more severe since coming off morphine.

Yesterday, I had three separate migraines in one day.

Three. 

Then I couldn’t sleep for most of the night until I knocked myself out with Tramadol, Paracetamol and Gravol. 

…when a regular facepalm just doesn’t cut it.

I’ve started a new migraine med (one that I have been on before with my previous neurologist, and that worked well) – Dosulepin. I see the new neurologist on June 26, and we figured since it takes at least a month to start working (same family as amitriptyline, and he’d likely want me back on it), we’d get a start on it.

I have also recently been diagnosed with polycystic ovaries (PCOS), which we’re treating and trying to get my reproductive cycle back on track. PCOS hormone treatment is proceeding on schedule, so we’re just waiting to see if I get a period in a few days, and then I go on Metformin. (“Bleed, dammit!”)

Here’s the pain scale I use; I’m rarely below a 7 these days.

Article: “How Doctors Die” – Thoughts on End-of-Life Care

I came across this article about end of life care…from the perspective of a doctor.

This could so easily become a rallying cry against doctors and “the medical establishment”. But I’ll try not to let it. I’m not going to give you platitudes about “dying with dignity” because I’m not certain there is such a thing.

Pain control isn’t perfect. You seem to have few choices:

-you’re unconscious from medication,

-you’re more lucid, but in agony,

-or you’re somewhere in between and unable to be awake enough to enjoy the useful and productive time you have with your friends and family even though your pain may, for the moment or a few hours, be under control (Hey, I can think straight! How much can I get done before this wears off! Should I work or play?)

You start measuring time by “when can I have my next dose of painkiller?”

The excerpt from this article speaks for itself:

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

One of the most basic human rights is, all too often, staved off by medicine: the right to die. Hopefully this article makes you think about some of the issues you may face if you’re ever diagnosed with a terminal illness.

New Diagnosis: Costochondritis

I’ve just been diagnosed with (tentatively) costocchondritis (inflammation of the cartilage in the ribcage). I’ve had bad rib pain for months and finally got up the courage to mention it to the doctor yesterday. When you have as many issues as I do, rib pain always seemed to get pushed to the back burner, but it’s been worse lately and I finally had enough.

I’ve already been taking ibuprofen for my leg inflammation, and it’s the same treatment for the ribs, plus heat packs (which I already use).

So it’s a little upsetting because there’s not much else we can do.

GP wil be doing a referral to a neurologist, after she reviews the notes from the last guy I saw in Glasgow. She needs to see all the meds we tried (in case I can;t remember one), and then we can make a plan what to try next.

My body’s just always falling apart! LOL

On “Transcending Pain”

I’m a chronic pain patient on morphine. (Note: As of 2013, I am no longer on opiates, but every day I wish I could have something, just a little, to take the edge off.) 

It amuses me when healthy people ascribe romantic ideas or evaluations of the experience of pain, especially chronic or severe pain the likes of which most of them have not experienced.

More than once, I’ve been told by different healthy people how inspiring I am, or how I rise above the pain to knit, study or just be a functional adult in my normal life. I’m not the first, nor the last, disabled woman to have this revelation (but this is an excellent post by the Disabled Feminist that reinforces my thesis).

On some level, I realize that most of them only mean well, but still, those types of people make me want to crush their larynxes with my boot.

They don’t usually see me, or other pain patients (such as my husband and sister who both have fibromyalgia), on the really bad days, because on those days, we’re not well enough to grace them with our magical, inspiring presence.

I’m betting that the screaming, throwing up and moaning from pain is sooo not in their idea of the romantic.

If, by the end of reading this post, you still think I and other disabled people are inspiring, please check out another post of mine, and a different post by the same blogger, Disabled Feminist.

But I hope, instead, that a lightning bolt of reality has benevolently struck you.