0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letters   |    
Atypical Migraine Manifesting as Mania
Ioana Iordache, M.D.; Bruno Gagnon, M.D., M.Sc.; Nancy C. Low, M.D., M.Sc.
The Journal of Neuropsychiatry and Clinical Neurosciences 2011;23:E18-E18.

To the Editor: This is a case report of a previously diagnosed “treatment-refractory bipolar” patient whose successful treatment of atypical migraine resulted in the questioning of any psychiatric diagnosis.

A 47-year-old man was referred to the Mood Disorders Clinic for severe migraine associated with mood, “psychic,” and neurologic symptoms. He had first presented to Psychiatry 8 years earlier, for acute “mania” with agitation, extreme lability, intense anger, and religiosity necessitating hospitalization. Subsequently, he had recurrences of similar manic “crises” followed by a “depressive” states consisting of cognitive dysfunction, avolition, and anhedonia. He also experienced severe headache and nonspecific neurological symptoms. A diagnosis of migraine was suspected, and a thorough neurological work-up did not yield other diagnoses. Medical history revealed multiple recurrent migraine-equivalents since childhood (particularly, abdominal pain).

Each psychiatric “crisis” was preceded by weeks of increasingly frequent, severe, early morning migraine attacks, with subsequent sleep deprivation, and intensification of migraine symptoms, including aura, with disorganized speech and thinking and bizarre behavior. A prolonged period of complete rest would break the cycle of migraine, accompanied by complete resolution of psychiatric symptoms.

Previous treatments included lithium, buproprion, as well as nortriptyline, stemetil, valproic acid, and quetiapine, none of which were helpful. Family history was positive for migraine and negative for psychiatric disorders. On referral, his medications were propranolol 40 mg twice daily, valproic acid 500 mg twice daily, and lamotrigine 100 mg twice daily. Valproic acid level was therapeutic. A diagnosis of mood disorder, bipolar type secondary to severe migraine was made.

This case illustrates the importance of inquiry of neurological symptoms, in particular headache, in patients with bipolar disorder. Patients with bipolar disorder have a greater-than-twofold risk of having migraine, as compared with the general population.1 Treatment for migraine, irrespective of mood disorder, includes amitriptyline, valproate, topiramate, and beta-blockers.2 In patients with bipolar disorder and migraine, judicious use of treatments for both disorders should be considered. Lamotrigine was used for this patient because valproate, although approved for both disorders,3 did not ameliorate the migraine symptoms. For bipolar disorder, lamotrigine is efficacious in the prevention of depressive episodes and, possibly, rapid-cycling type.4 Less evidence supports its use in acute depression or mania.4 For migraine, lamotrigine was not beneficial in a placebo-controlled trial, but had some effectiveness in two open pilot studies for the treatment and prevention of migraine aura.2

Lamotrigine is generally well tolerated, with an acceptable side-effects profile (mainly dizziness, nausea, and insomnia), and may be considered for a patient with aura nonresponsive to other medication. Slow and low dose increase is recommended for side-effects monitoring, especially for severe rashes and Steven's Johnson syndrome. In our patient, lamotrigine was increased to 200 mg twice daily. Use of lamotrigine with valproate may increase lamotrigine concentrations by up to 200% because of increased lamotrigine clearance inhibition,3,5 and valproate levels may also decrease.3 The patient's headache duration eventually decreased to 1 hour nightly, and he returned to work full-time with a 45-minute nap.

Low  NC;  Du Fort  GG;  Cervantes  P:  Prevalence, clinical correlates, and treatment of migraine in bipolar disorder.  Headache 2003; 43:940–949
[PubMed]
[CrossRef]
 
Silberstein  S:  Preventive migraine treatment.  Neurol Clin 2009; 27:429–443
[PubMed]
[CrossRef]
 
Canadian Psychiatric Association CPS 2009:  Compendium of Pharmaceuticals and Specialities, The Canadian Drug Reference for Health Professionals, 2009;  Canadian Pharmacists Association,  Ottawa, Ontario, pp 1238–1244
 
Bowden  CL:  Anticonvulsants in bipolar disorders: current research and practice and future directions.  Bipolar Disord 2009; 11(Suppl 2):20–33
[PubMed]
[CrossRef]
 
Kanner  AM:  When thinking of lamotrigine and valproic acid, think “pharmacokinetically”! Epilepsy Curr 2004; 4:206–207
[PubMed]
[CrossRef]
 
References Container
+

References

Low  NC;  Du Fort  GG;  Cervantes  P:  Prevalence, clinical correlates, and treatment of migraine in bipolar disorder.  Headache 2003; 43:940–949
[PubMed]
[CrossRef]
 
Silberstein  S:  Preventive migraine treatment.  Neurol Clin 2009; 27:429–443
[PubMed]
[CrossRef]
 
Canadian Psychiatric Association CPS 2009:  Compendium of Pharmaceuticals and Specialities, The Canadian Drug Reference for Health Professionals, 2009;  Canadian Pharmacists Association,  Ottawa, Ontario, pp 1238–1244
 
Bowden  CL:  Anticonvulsants in bipolar disorders: current research and practice and future directions.  Bipolar Disord 2009; 11(Suppl 2):20–33
[PubMed]
[CrossRef]
 
Kanner  AM:  When thinking of lamotrigine and valproic acid, think “pharmacokinetically”! Epilepsy Curr 2004; 4:206–207
[PubMed]
[CrossRef]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Books
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 2.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 2.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 5.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 11.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 23.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles