By MacReady, Norra
Clinical Psychiatry News , Vol. 32, No. 4
RANCHO MIRAGE, CALIF. -- Women with migraines often have comorbid conditions that require coordination of care to address what may be intertwined problems, Dr. Lisa K. Mannix said at a meeting sponsored by the Diamond Headache Clinic.
She illustrated this approach by describing a patient who complained of headaches and had several comorbidities that complicated diagnosis and management.
The 15-year-old girl experienced two or three throbbing headaches per month, usually around the time of her menstrual period. The headaches were associated with nausea and photophobia. She missed 3 days of school each month because of the headaches. The girl's mother said that the girl frequently experienced loose stools, and that she argued often with her stepfather and her siblings.
The patient was 5 feet 6 inches tall and weighed 125 pounds. Her vital signs were normal. Her neurologic examination also was normal, but her affect was somewhat flat. The rest of her physical examination was unremarkable, said Dr. Mannix, a neurologist in private practice in Cincinnati.
Based on the diagnosis of migraine without aura, the patient was instructed to keep a diary of symptoms to determine if the episodes were related to her menstrual cycle.
Possible comorbidities in this case included an eating disorder, irritable bowel syndrome, depression, anxiety, premenstrual syndrome, and premenstrual dysmorphic disorder.
When trying to identify comorbidities in patients with migraine, these issues should be considered:
* Eating disorders. These often coexist with headaches. Tip-offs on the physical examination include amenorrhea, bradycardia, hypovolemia, and peripheral edema. Women who vomit may have erosion of tooth enamel.
* Irritable bowel syndrome. This condition, characterized by loose stools, cramping, and discomfort, is easy to miss if the patient also has an eating disorder. Some patients have associated migraine headaches.
If irritable bowel syndrome is suspected, ask the patient to keep a diary of her bowel habits to identify episode triggers; the same triggers may precipitate her headaches. Treatment includes advice on diet and exercise, information on stress management, and possible pharmacologic interventions--including antispasmodic agents, antidepressants or anxiolytics, and fiber or laxatives, depending on symptoms.
* Mood disorders. People with depression or anxiety have a higher risk of headaches than the general population, according to Dr. …