Psychiatric Illnesses and Fibromyalgia
There’s an interesting and important article in last month’s issue of the Journal of Clinical Psychiatry, by a group of investigators from the University of Cincinnati.
They have shed important new light on fibromyalgia. We’ve recently learned how it is linked to disturbances of the serotonin transporter, as well as anti-inflammatory proteins, and that is may respond best to the kind of comprehensive multi-leveled approaches that we use in Integrated Medicine.
The new research compared people with fibromyalgia with people with rheumatoid arthritis, and it found that fibromyalgia, but not rheumatoid, may be associated with a range of psychiatric illnesses:
- Major depressive disorder
- Bipolar disorder
- Comorbid anxiety disorders including panic disorder, social phobia, posttraumatic stress disorder and obsessive-compulsive disorder
- Eating disorders and
- Substance abuse
What was particularly important in this study was that the psychiatric problems usually preceded the onset of fibromyalgia. So it wasn’t that people were developing psychological problems because they were in chronic pain.
It’s beginning to look as if fibromyalgia is part of a larger group of disorders that all share common etiologies or causes. Family studies have indicated that fibromyalgia and mood disorders share some of the same – perhaps genetic – determinants.
The study also confirms what we have said before: fibromyalgia is not only associated with some psychiatric problems, but also with other medical disorders, several of which may also co-exist with the same psychiatric problems. They include:
- Chronic fatigue syndrome
- Irritable bowel syndrome
- Interstitial cystitis
- Multiple chemical sensitivities and
- Migraine
Not only does this research highlight the need to check people with fibromyalgia to see if they might also be struggling with a psychiatric problem, but it is helping us home in on some of the mechanisms linking these apparently separate problems.
This particular study was done mainly in white women, and the investigators knew who had fibromyalgia, so there’s more work to be done.
But if you or a loved one is struggling with fibromyalgia, it is good news to know that we are making rapid progress in unraveling this horrible illness.
Migraine and Bipolar Disorder
Back when the world was new, I cut my teeth in migraine research, and migraine and other headaches were the topic of my first book. So I’ve always kept an eye out for new developments.
There’s an interesting case report from India, about a nineteen year old who developed mild mania as part of the aura or warning of his attacks. This sort of case is interesting for what it might be able to teach us about each illness. It is also good for us to know that bipolar disorder is highly co-morbid: it is associated with many other illnesses apart from migraine:
1. Anxiety disorders
2. Substance abuse disorders
3. Attention deficit disorders
4. Personality disorders
5. Impulse control disorders
6. Eating disorders
7. Insulin resistance
8. Obesity
9. Diabetes mellitus
10. Cardiovascular diseases
11. Pain disorders
This is why diligent clinicians are always on the lookout for bipolar disorder: if it is missed and remains untreated, it can cause havoc: suicide attempts, damaged relationships, substance abuse and general misery.
Migraine is one of the vascular headaches that is occasionally associated with an array of other vascular problems, like Raynaud’s phenomenon, ischemic heart disease and stroke. But the aura is something else altogether. For many years it was thought that the migrainous aura was a result of a reduction in blood flow to regions of the cerebral cortex. Almost 25 years ago that was shown to be inaccurate. It is due to a release of witches’ brew of excitatory and inhibitory amino acids in the cortex. It is highly likely that the release of excitatory amino acids is the explanation for the manic symptoms.
Migrainous mania is evidently rare, but apart from visual disturbances, I’ve seen all sorts of strange auras: sudden food cravings; intense sweating; extreme irritability and many other things besides.
The treatment of migraine still revolves around avoidance or modulation of triggers, pain relief and prophylaxis. The big change in recent years has been the increasing amount of experience and small amount of evidence indicating the value of non-pharmacological approaches like spinal manipulation, temporomandibular joint adjustment, acupuncture, the tapping therapies and homeopathy.
To an integrated practitioner, the key is to understand the problem as more than just headache: we can guide a person to see the problem in its broader context, as a challenge designed to find a path toward inner wellness. We also see it as a process that has meaning and purpose and is a Divinely inspired invitation to grow spiritually and as an individual.
That may sound a lot for a headache, but it is the best possible way to triumph over the problem!
“The cure of the part should not be attempted without treatment of the whole.”
–Plato (Athenian Philosopher, 428-348 B.C.E.)
Technorati tags: Migraine Bipolar disorder Insulin resistance Attention deficit disorder AnxietyIntegrated medicine
Acupuncture for Migraine
It was frustration at being unable to help so many people with migraine, that first lead me to begin my training in acupuncture. At the time I was working as a young research fellow in the main migraine clinic in London and I quickly discovered that acupuncture could be a wonderful treatment for many people suffering from this illness. I did my advanced training in acupuncture in China and even there – working with some of the best practitioners in the world – I confirmed my observation that acupuncture is no panacea. But it is a very helpful addition to our therapeutic toolbox.
There is a most interesting article in this week’s Lancet Neurology, that was also picked up by the BBC. The study came from Germany, and involved 960 patients who were randomly assigned to normal migraine medication treatment, traditional acupuncture, and sham – or fake – acupuncture. People in all three groups got better, and there was nothing to choose between the treatments in terms of efficacy.
So what does that mean? That acupuncture was in this trial as good as medications. But it adds to the growing literature that indicates that the precise placement of needles is not always as important as we used to think. But we also need to know exactly where the “sham” needling was done. During my years with the Research Council for Complementary Medicine and Prince Charles’ Foundation for Integrated Medicine, I saw a great many studies and proposals for studies in which the “sham” needles had actually been placed in highly active acupunctures points.
When I was training in China, most of my fellow students had trained in classical acupuncture in Europe, and some were outraged when they heard Chinese professors of acupuncture say that only some acupuncture points were always in the same place, and that it was not necessary to follow all the classical teachings. Some of the Europeans felt that the Chinese were destroying an ancient legacy. The Chinese simply responded by saying that the practice of acupuncture was being evolved on the basis of clinical observations and empirical research. It looks as if they were correct!
Technorati tag: acupuncture, migraine
Migraine and Hormones
Migraine (can be a frightfully difficult problem to treat. It is such an interesting puzzle, that the first book that I ever wrote was on migraine and other types of headache. Migraine is a great deal more than just a severe headache. It is can also be associated with neurological symptoms, and people often become exquisitely sensitive to light and sound. Additionally, at the beginning of the attack, the stomach stops working properly, which can make the absorption of medicines very difficult. Then comes the vomiting and sometimes diarrhea.
Although migraine is usually described as a “vascular” headache, there are strong reasons for thinking that it is more than that. People who suffer from the classic type of migraine often have spreading visual problems or partial visual loss, which goes on for between ten and sixty minutes. These visual problems are likely the result of a spreading wave of neurological depression spreading over the visual cortex at the back of the brain. The sensitivity to light and sound suggests that something is going wrong in the neurological systems that normally filter sensations, and the gastrointestinal problems indicate that something is going wrong in some of the control centers of the brain. There are some real oddities about migraine: it is exceptionally uncommon in people with diabetes; appears to be slightly more common in people who are left handed and is one of the only illnesses that tends to gets better as we get older.
There are a number of well-known triggers to migraine attacks. Though the scientific literature on triggers is not conclusive, here are some of the more common ones, that if avoided, have helped a great many people:
- Stress (either during stress, or when the pressure comes off)
- Cheese
- Chocolate
- Coffee
- Citrus fruit
- Red wine
- Changes in the weather (especially when there are a lot of positive ions in the atmosphere)
- Mono-sodium glutamate (MSG)
One of the best-known features of migraine is that it is considerably more common in women and that there is often a relationship between headaches and phases of the menstrual cycle, in particular during the pre-menstrual days. There have been many small studies that have indicated that oral contraceptives might increase the risk of suffering from migraine. A new study from Trondheim in Norway, has confirmed a link between oral contraceptive and migraine. The Nord-Trøndelag Health Study was done between 1995 and 1997. It included 14,353 pre-menopausal women, of whom 13,944 (97%) responded to questions regarding their use of contraceptives. There was a significant association between migrainous and non-migrainous headaches and the women’s reported use of estrogen-containing oral contraceptives. An important finding was that there was no relationship between the number of headaches and the amount of estrogen in the contraceptive pill.
There is one more thing to factor into the equation. Over the last two decades, there have been many reports of an association between certain types of migraine and cerebrovascular accidents (“strokes”). In the largest analysis of the data, that was published in the British Medical Journal, there was indeed a higher rate of strokes in women who had migraine and who were taking oral contraceptives. These studies included some of the older ones done in the days when the doses of hormones were higher than they are today, but when making decisions, it is important to be aware of this rare association.
An editorial in the British Medical Journal made these recommendations, with which I agree:
1. In an otherwise healthy young person, there is little cause for concern because the absolute risk of stroke is very low.
2. People with migraine who are on oral contraceptives have another reason for not smoking
3. Use low dose estrogen or progesterone only contraceptives in young women with migraine.
4. Although there isn’t much good evidence, many neurologists suggest stopping oral contraceptive pills if the migraine becomes more frequent or changes in character.
5. The risk of stroke gradually increases over age, particularly in smokers, so a slightly older smoking woman with migraine, should probably not be taking an oral contraceptive, unless it is the only option for her.
Technorati tags: migraines,hormones, headache, womens health
