Migraine but treated as hypertension

MM a 45 year old teacher who has been on my hypertension clinic follow up  for two years, one day asked me whether her younger sister, JM could come and see me for her hypertension problem . Of course I would not mind. The sister, five years younger finally came to see me a few months back.

I let her to slowly narrate me her problem and later I was able to  summarise it as someone who has been suffering from frequent attacks of migrating headaches since her early twenties and had been taking a lot of pain killers that had led her to suffer from epigastric pain accompanied by nausea and vomiting 

Five years ago she had gone to see a doctor due to intractable headaches, nausea and vomiting with blurring of vision. The doctor took just one reading of her blood pressure and then told her that he had high blood pressure and needed an antihypertensive (blood pressure-lowering drug). She has been taking the drug ever since whilst her frequency of headaches had not receded.

Lately she had been having more frequent attacks which according to her were brought on by stress. At the same time she had increased her dose of over the counter (OTC) cafergot, to relieve her headaches. And she had been going to different doctors  who continue to prescribe her with the antihypertensive for her supposed high blood pressure and pain killers for her chronic headaches which by this time have the characteristics of  a migraine.

Migraine headaches can be debilitating and affect quality of life.

I monitored her hypertension for about two months and noticed that her blood pressure was consistently abnormally low despite my lowering the medication dosage.  I decided to rest her from the drug for two weeks with a daily home monitoring of her BP and observed that she actually did not have hypertension (BP > 140/90). I promptly stopped the medication and concentrated on her migraine. I told her that she has to stop taking pain killers and cafergot as her liver is showing some injury from  such drug usage based on her deranged liver function tests. The likelihood of her suffering from  chronic peptic (stomach) ulcers is also great  due to those painkillers.

After a general neurological assessment, I then prescribe a drug, a tricyclic anti-depressant for her as an off-label treatment for migraine. The medication has greatly reduced the headache attacks and she has felt so much better. Of course not all people respond alike. Some migraine sufferers do no benefit from this drug,  JM is just fortunate to have responded well. I also tell her to have a headache diary to record all the circumstances that could trigger her attacks like foods, drinks and emotional situations. Identifying these factors could help her to manage the attacks better.

In the meantime her blood pressure has remained normal and so does not warrant any drug.

There are many pitfalls regarding the diagnosis of hypertension as it  could be influenced by many factors like  over-anxiety and extreme tiredness and lack of sleep or even pre-consultation caffeine drink. It is also unwise to start this lifelong treatment based on just one reading of the sphygmomanometer. Unless the BP is extremely high, monitoring it for a week or so would give an idea whether there is actually hypertension.

So JM who has been on treatment for her "alleged" hypertension for more than five years actually just needs an appropriate medication for her migraine headaches.