Understanding Chronic Pain

NARCOLEPSY, PHOBIA AND PAIN

"It is much more important to know what sort of patient has a disease than what sort of disease a patient has."

                                                        Sir William Osler

A 40 year old woman came to me with a one year history of progressive migraines. They had not responded to conventional therapy. In the course of my interview I learned that she was increasingly anxious over the interval of her migraines and also quite sleepless.

 I pursued an issue that I have only recently learned can be quite important. I asked if she was subject to vivid dreams, and she told me that she had dreams which she felt were almost real. Oftentimes when she awoke from them she was paralyzed and unable to move. In response to my questions she told me that she did have occasional spells of loss of muscle strength, causing her to suddenly fall. 

She had more than migraine. She had narcolepsy with vivid dreams (known as hypnagogic hallucinations), sleep paralysis, and cataplexy (sudden brief loss of muscle strength). Although she denied daytime sleepiness, she fulfilled my diagnostic criteria for narcolepsy.

I chose to treat, not her migraines, but her narcolepsy, and my choice of therapy was counterintuitive. I gave her the stimulant Ritalin, a drug which helps narcolepsy, but which often worsens migraine. Ritalin increases blood vessel reactivity and migraine is a disease of blood vessel reactivity. Conventional thought would suggest that the Ritalin would make her migraines worse -- but the effective treatment of pain is often unconventional.

Ritalin did not make her migraines worse. It arrested them, and as it did so, her dreams stopped, as did her sleep paralysis and cataplexy. Her anxiety abated, and this happened over the course of but a few days.

In my writings I often use the phrase "when the right drug kicks in, everything gets better." In addition to the improvement in her migraines, her anxiety and her dreams, she also experienced improvement in a remarkable and unexpected manner. She had always had a phobia about going to the dentist and had required some kind of sedative medication before entering a dental office. However, with the Ritalin on board,  she felt so confident when she went to the dentist that she didn't request sedation. She stepped into the dental chair fearlessly, and her procedure was performed without difficulty. 

In this case, it certainly was more important to know what sort of patient (narcoleptic and phobic) I was dealing with than what sort of disease (migraine). 

Last Updated: Dec 10, 10:07 AM

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