Understanding Chronic Pain

Obsessive Compulsive Disorder, Migraine, and Narcolepsy

I continue to be impressed with the remarkable capacity of pharmacy to relieve not only pain, but also many other bad things. This is the reason I so often employ, in my writing, the phrase "When the right drug kicks in, everything gets better."

 A fifty year old woman came to me because of increasing frequency of her migraines. She denied depression (a frequent cause of increasing frequency of migraine), but on her intake history she recorded that she was taking the SSRI drug, Luvox, (akin to Prozac and Zoloft). I inquired as to why that particular drug, and she told me it was for treatment of her obsessive compulsive disorder. 

Luvox is an antidepressant, but it has particular usefulness for the treatment of obsessive compulsive disorder (OCD).and is widely employed for that purpose.

In response to my inquiries, she told me that her OCD manifested in a not uncommon way. Whenever she walked on a patterned surface, such as a tile floor or a brick wallkway, she felt compelled to step on every other tile or brick, and if she failed to do so, she would experience fearful anxiety to the point of panic. When these were severe, she told me she would lose control of her muscles and actually fall. She also told me that the Luvox was helping but little.

I continued my interview and found none of the common antecedents that predict a life of painfulness. I did, as I am now increasingly inclined to do, inquire as to whether she had vivid dreams because I have learned that narcolepsy is a frequent companion to pain,and that vivid, sometimes terrifying dreams are one of the hallmarks of that disorder.

She told me that she did indeed suffer dreams, that they seemed real to her,  that she actually lived them. In response to my questions she told me that, yes, on occasion she did awaken suddenly from a dream feeling paralyzed and unable to move for a few moments. She acknowledged daytime sleepfulness and attacks of nodding off when she no business doing so.

She already fulfilled my criteria for the diagnosis of narcolepsy. The vivid dreams are a form of hallucination, and they are called hypnagogic hallucinations (hypnagogic refers to that twilight interval between wakefulness and sleep when the dreams most often occur). She also suffered sleep paralysis, which is the awakening from a dream unable to move. Daytime sleepfulness, as most everyone knows, is the cardinal feature of narcolepsy, but I had one more question, and that related to the phenomenon of cataplexy. It refers to the sudden loss of muscular tone causing the victim to suddenly collapse to the ground, or to unaccountably drop things they are holding. It is a very common in narcolepsy.

"Yes, " she replied, "that's just what I told you about when I misstep and become anxious. I fall down."

 Remarkable indeed -- and I should have picked up on it sooner. Drop attacks, are highly suggestive of narcolepsy, and my patient had the disease in spades, although she had never consulted a physician about it.

Here I was, with a patient with progressive, accelerating migraines, narcolepsy, and obsessive compulsive disorder. Could there be a connection?

I have learned, through years of experience, that when confronted with a patient with pain and a neuropsychiatric illness, be this depression, bipolar disease, or even narcolepsy, attention should first be directed to the neuropsychiatric illness, because by treatment of that disorder, the pain can often be cured.

I prescribed the time-honored and well-recognized treatment for narcolepsy, Ritalin. It is an unlikely drug for the treatment of migraine and certainly unlikely for the treatment of obsessive disorder, but my instincts told me to try it.

She returned at the appointed time to excitedly tell me that her migraines were much diminished and that her bad dreams had gone away. She then volunteered that her fear of misstepping on the wrong tile had gone away and that she no longer suffered anxiety when she misstepped. Nor did she experience drop attacks.

When the right drug kicks in, everything gets better. It is uncanny. There was absolutely no reason to expect such a dramatic improvement in her obsessive compulsive disorder as I treated her narcolepsy -- and with it, her migraine -- but that is exactly what happened.

The visitor may want to peruse the story from one of my previous blogs about the young woman with progressive migraine who also suffered narcolepsy with vivid dreams, sleep paralysis, and cataplexy. Her phobia of going to dentists, which she had not even told me about, went away simultaneously with all the rest when I treated her with Ritalin.

What does it all mean? What is the relationship of narcolepsy to migraine and to obsessive compulsive disorder and to phobia? It will turn out to be a fascinating study, I am sure, and very possibly pave the way to successful treatment, not only of migraine and narcolepsy, but also phobias and obsessive compulsive disorders, the latter two among the most pharmacy-resistant of all the psychiatric diseases.

I invite your comments on this interesting matter.

Last Updated: Apr 29, 12:25 PM

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Angel_john316@yahoo.com Trichotillomania, Pain, Bipolarity and the Curious Effects of Polypharmacy