ABSTRACT:
The association between migraine and major depressive disorder is stronger for patients who have migraine with aura. Following isa case report of migraine with aura which was associated with depression in a 39 years old female. The search towards the homoeopathic medicine is through the periodic table approach.The patient showed marked improvement in migraine along with its comorbidity with the indicated constitutional medicine in 6 months which was assessed by using MIDAS scale and patient health quality (PHQ)-9.
KEYWORDS: migraine with aura, depression, Natrum muriaticum
ABBREVIATIONS: DALYs- disability-adjusted life years, DM- diabetes mellitus, HTN- hypertension, OA- osteoarthritis, C/O- complaints of, A/F- ailments from, <- aggravation, >- amelioration, H/O- history of, FU- follow up, MIDAS- migraine disability assessment scale, PHQ – patient health quality, CT – computed tomography, MRI – magnetic resonance imaging, LMP – last menstrual period.
INTRODUCTION:
“It’s not just pain. It’s a complete physical, mental, and emotional assault on your body”- Jamie Wingo1
Headache in 2019 ranked 14th among global causes of DALYs2. Migraine affects an estimated 12% of the population3.
The association between migraine and major depressive disorder is stronger for patients who have migraine with aura. The relationship between migraine and depression appears to be bidirectional4.
One comes across lots of literature which narrates on utility of homoeopathic remedies in migrainous condition. In the following case, one can nicely correlate the history of the patient with the schematic presentation of Natrum muriaticum through periodic table approach. Also, correlation of migraine with one of the psychiatric comorbidities i.e. depression can be highlighted through her life events. The way in which patient’s life was revolving around relationship and trust, with difficulty to cope up from it, it indicated towards the group of remedies from mineral kingdom.
CASE STUDY
A 39 years old housewife, visited A M Shaikh Homoeopathic hospital OPD with complaints of severe headache on 26/6/2020. The headache was present since last 1 year but intensified since the last month.
Ailments- Change of routine, fine work, sleeplessness
Location: Unilateral, right sided
Duration: Headache once in 10 days for 1 month. Previously 1- 2 times in a month.
Sensation: Pulling type of pain, feels darkness before the eyes, photophobia, nausea during headache.
Modalities:
<–Pressing+++, shouting, bending forward, sneezing while, coughing [has to hold head and do act]
>– Sleep after, rest, putting oil in the ear
PAST HISTORY-
Similar complaints in the past for which she took homoeopathic medications.
FAMILY HISTORY-
Father-expired due to chronic diabetic renal complications
Mother-DM, HTN and OA- under homoeopathic treatment
Sister- allergic complaints
PHYSICAL CHARACTERISTICS:
APPEARANCE: Lean, thin, emaciated, fair with pale appearance.
Conjunctiva and nails are pale.
DIGESTION: Patient prefers non-veg more withmarked desire for salt 2+, fish 3+anddoes activities Slow.
ELIMINATION: Stools once a day, unsatisfactory, hard, not cleared easily.Urine 4-5 times/day, 1-2 times/ night, pale yellow. Perspiration is generalised.
MENSTRUAL HISTORY- Attained menarche at 13 yrs of age, cycles regular with no other complaints.
Life space investigations
As narrated by the patient that she belonged to a well-to-do family, “I had no worries emotionally or financially. We were 4 siblings [2 girls,2 boys]. For me, all decisions were taken by my family, because I believe they do it for my betterment. Even selection of clothes was by my sister, mother. I don’t choose them as I know they will do it for me.
I married 2 times……….
My first married life had very bad phase. It was arranged marriage. I have a child with him. He was orthodox from the beginning. He used to put restriction and keep me bounded. I could still tolerate it, but later he started torturing me. Physical abuse…. torcher…. he used to beat me. I had never expected it be like this. It was out of my tolerance. I still think that whether I have done something wrong or have I not done enough to maintain the marriage. Did I lack somewhere? My father took me and my son back with him. And I got divorced….
After few years, I married for second time to a divorcee. He also has a boy child younger to my son. His wife also left him. Marring for second time was not at all my thought. My parents convinced me continuously to do so and think about future of me and my child.
Even this marriage is out of my expectation. I feel like my son is been not taken care by him. He does lots of partiality in both sons. But never expected it to be so. I expect lots of care, love and affection. We are been provided every necessary thing but no affection, it’s just materialistic way. No caring.
I also deserve affection……it lacked in previous marriage and now also the same.
I always go in deep thoughts of it, why so? Why me only?
This is affecting somehow on my health. I can’t control my thoughts, become sad, doesn’t feel like to do anything.
Thoughts remain in my mind even if the talk is over also. I will be always thinking about the past events for long and then tears come, but I don’t cry in front of people.
Since 2-3 years I have changed….. this was first told to me by mother and later I am also observing….. I shout for small things also…..shouts at anybody …..sometimes without reason ……..suddenly I go in deep thoughts……thinks about my messed life…….don’t feel like to do anything…….slowly I start with headache sometimes……I was never like this before…….don’t know how to come out of it”.
Irritability – used to shout at son and husband but later repents, felt better when she shouted at them. Couldn’t vent out the anger on other people.
Empathy- if anybody was in trouble, she used to feel bad. If anyone was unwell, nobody told her about it, she will be throughout thinking about incidence and it will affect her health.
Incidence- her cousin sister’s husband died due to COVID-19. After hearing about it, her health condition worsened due to overthinking.
She used to think if anyone would be there for her or not. “Was she alone?” When she had such thoughts, she went to her mother’s place.
During headache, she became nervous, depressed, couldn’t tolerate the pain, and lost all hope.
DIFFERENTIAL DIAGNOSIS5:
| DISEASE | SYMPTOMS | INVESTIGATIONS | |||
| HEADACHE | OTHER SYMPTOMS | ||||
| ONSET | CHARACTERISTICS | ||||
| MIGRAINE | Sudden | Severe to moderate pain, unilateral, pulsating, 4-72hrs | Preceding aura Nausea Vomiting photophobia phonophobia | Clinical diagnosis CT and MRI- to rule out other suspected possible cause for headache | |
| CLUSTER HEADACHE | Sudden | Unilateral, periorbital, minutes to hours, throbbing | Conjunctival injection, lachrymation, rhinorrhoea | ||
| TENSION HEADACHE | Sudden | Mild to moderate pain, bilateral, constricting pain, minutes to days | None | ||
DIAGNOSIS:
International classification of disease -10-CM6
According to 2022 International classification of disease -10-CM diagnostic code —-
Migraine with aura- G43.1
International classification of headache disorders III [ICHD-III] diagnostic criteria for migraine with aura7:
Justification
Patient came with the complaint of headache. A few of the ideas which popped up into the mind while taking case in regards to diagnosis was tension headache, sinusitis, cluster headache and migraine. While coming through the series of symptom presentations and getting a clear picture of unilateral headache with aura, it was differentiated from other types of headaches.
CASE ANALYSIS:
As it is more thematically pointing towards RELATIONSHIP and DEPENDENCY, one could divert his mind to MINERAL KINGDOM8.
MINERAL KINGDOM—–
ROW DIFFERENTIATION—-
When one goes through the understanding of second row, Nourishment derived is from inside. Attachment is like within the other, cannot think of existence outside of that. Often their keyword is “I cannot have an independent existence”9.
Whereas in third row, attachment is where one derives all nourishment and care from the outside. They have independent existence. They seek relationships where there is understanding, familiarity, comfort, communication, confidence, trust and attachment10. Feeling is” she and I are not different, she is mine, and therefore I will not be let down in anyway”9. The decisions are impulsive and also instinctive.
Similarly, in fourth row, the issue is mainly to go with money, house, bank balance, insurance, etc. Here they need to trust that their job, bank balance is secured. Whereas in row 3 trust is associated with empathy. They start becoming calculative. Planning here is short term but not an obsession like row 3. They look for more steadiness, stability, and are practical, pragmatic9.
Row 3 features were matching our patient’s characteristics.
COLUMN approach ——-
The main feeling of Magnesium muriaticum is that his trust and faith in the people he depends so much upon will be betrayed, and he will be disappointed.
Natrum muriaticum feels both disappointed and betrayed, as a result, he feels irritable and angry. The relationship she seeks is not one of dependence like Calcarea or Magnesium but of friendship or romance, a relation on a one-to-one basis.
Natrum muriaticum has no identity of her own, doing what others decided for her. Seeks for love and care.
Sepia officinalis comes close to Natrum muriaticum. Both have the theme of disappointment. The main contradiction of Sepia officinalis is between relationship and occupation, but not between making and breaking the relationship as seen in Natrum muriaticum10.
Similarly, patient agreed to whatever decision made by her parents for her showing segment of dependency. Even after 2nd marriage, somewhere that love, care and affection was lacking. It’s just materialistic way. No caring. Dwelling upon past memories. Felt empathised about others. Felt better when weeping alone. Along with these complaints, some of the physicals, desire for fish, salt, fair complexion, with thin built and particulars point towards the remedy.
Natrum muriaticum was selected for the patient seeing all her complaints. The remedy was started in 30 potency OD for 3 days early in the morning.
Along with it, the patient was counselled regarding her stress issues.
TOOLS USED-
These scales were used at baseline and last follow up to assess severity and progress during the period of medication.
Tools used to assess severity of migraine & depression with progress of symptoms after medication included-
A] Migraine disability assessment scale [MIDAS]4
B] Patient health quality (PHQ)-94
The migraine disability assessment scale [MIDAS]:
| QUESTIONS | First visit | Last visit |
| 1. On how many days in the last 3 months did you miss work or school because of your headaches? | 4 | 2 |
| 2. How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school.) | 3 | 2 |
| 3. On how many days in the last 3 months did you not do household work (such as housework, home repairs and maintenance, shopping, caring for children and relatives) because of your headaches? | 3 | 2 |
| 4. How many days in the last 3 months was your productivity in household work reduced by half of more because of your headaches? (Do not include days you counted in question 3 where you did not do household work.) | 2 | 0 |
| 5. On how many days in the last 3 months did you miss family, social or leisure activities because of your headaches? | 1 | 0 |
| TOTAL—- | 13 | 6 |
What your Physician will need to know about your headache:
| A. On how many days in the last 3 months did you have a headache? (If a headache lasted more than 1 day, count each day.) | 4 | 1 |
| B. On a scale of 0 – 10, on average how painful were these headaches? (Where 0=no pain at all, and 10= pain as bad as it can be.) | 7 | 2 |
1st visit= 13- MIDAS Grade III Moderate disability
Last visit= 6- MIDAS Grade III Mild disability
Patient health quality (PHQ)-9—-It was used at baseline tool to assess depression severity.
| Over last 2wks how often you are bothered | Not at all | Several days | More than half the days | Nearly every day | |||||
| 1ST Visit | Last visit | 1st visit | Last visit | 1st visit | Last visit | 1st visit | Last visit | ||
| 1] little interest or pleasure in doing things | 0 | 2 | |||||||
| 2]Feeling down, depressed or hopeless | 1 | 3 | |||||||
| 3]trouble falling or staying asleep | 1 | 3 | |||||||
| 4] Feeling tired or having little energy | 2 | 3 | |||||||
| 5] poor appetite or overeating | 0 | 0 | |||||||
| 6]feeling bad about yourself | 1 | 2 | |||||||
| 7]trouble concentrating on things such as newspaper | 0 | 1 | |||||||
| 8]moving or speaking so slowly that people notice around | 1 | 1 | |||||||
| 9]thoughts that u would be better off dead | 0 | 0 | |||||||
1st visit score —15 – moderately severe depression
Last visit score – 6—mild depression
FOLLOW UP:
| FOLLOW UP | COMPLAINTS | PRESCRIPTION | REMARKS |
| FU-1 9/7/20 | Patient was better similar episodes of headache but with less intensity, could bear them. Whenever pain starts, nervous feeling [whether she is going to survive or not] Sensation as if headache will eat her up Yesterday 2-3 times vomiting with headache Appetite-decreased | 1]Pl-15 days 4-0-4 | Though headache persisted severity was better, so continued with placebo. Never repeat the remedy as long as improvement persist11. |
| FU-2 10/8/20 | Rt sided frontal headache Pain from frontal region goes till nape of the neck Shifting pain from right to left side Throbbing pain- >– by massage+++ Vomiting- 1 episode Mind- less irritable on silly things, just think before shouting on son. Getting sound sleep and much past thoughts. App- reduced with bitter taste in mouth | 1] Natrum muriaticum 30 /3doses 2]Pl-30 days 4-0-4 | Similar complaints, so the medicine was repeated. When improvement ceases, give the remedy in the potency first chosen11. |
| FU-3 14/9/20 | Patient much better Headache frequency reduced Now able to stitch, do fine works | 1] Pl- 1 month 4-0-4 | |
| FU-4 25/11/20 | Headache complaints similar as before Patient was out of station, so couldn’t report for month follow up. | 1] Natrum muriaticum 30 /6 doses 2] Pl- 1 month 4-0-4 | Potency same as patient was responding to it, but raised the dose. Dr Hahnemann in 6th edition of Organon of Medicine has advised for the repetition of doses in chronic cases11. |
| FU-5 11/9/20 | Headache episodes reduced, now occasionally Burning in both eyes Generalised weakness++ for 1 month A/F-death in family during COVID-19 period Menses- LMP-29/8/20 Flow- moderate | 1]Kalium phosphoricum 6X- 16 DOSES 0-0-2 2]Pl -1month | Gave biochemic remedy for neuralgic pains with depression and sleeplessness11. Did not repeat Natrum muriaticum as she was better. |
| FU-6 6/10/20 | Feeling much better now Episodes of headache reduced Disturbed sleep because some guests visited the house. | 1] Kalium phosphoricum 6X-– 16 DOSES 0-0-2 2]Pl -1month | |
| FU-7 9/11/20 | Feeling good No episodes of headache Now able to sleep | 1]PL-15 days |
Prognosis: Long term studies support the concept that remission increase with age13. Identifying predictors of migraine and working on it, helps towards good prognosis.
Treatment plan: Though the complaints are reduced, there are chances of remission as stated above. The patient was followed up to see for its recurrence.
CONCLUSION: In this case of migraine with aura, constitutional homoeopathic medicine selected on the basis of knowledge of 3rd row of periodic table, not only cured the condition but also depression, thus proving it to be holistic method.
LIST OF REFERENCES:
1] Image: Jamie Wingo Quotes https://images.app.goo.gl/BZzo1mTczjwDCUT56
2] Steiner TJ, Stovner LJ, Jensen R, Uluduz D, Katsarava Z. Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019.The Journal of Headache and Pain (2020) 21:137 https://doi.org/10.1186/s10194-020-01208-02
3] Rebecca C Burch et al. Migraine: Epidemiology, Burden, and Comorbidity. Neurologic clinics. Vol 37, Issue 4, Nov 2019, Page 631-649 https://doi.org/10.1016/j.ncl.2019.06.001
4] Minen MT, et al. Migraine and its psychiatric comorbidities. J Neurol Neurosurg Psychiatry 2016; 87:741–749. https://jnnp.bmj.com/
5] “Differential Diagnosis of Headache” https://ddxof.com/headache/
6] “2022 ICD-10-CM Diagnosis Code G43.1: Migraine with aura” https://www.icd10data.com/ICD10CM/Codes/G00-G99/G40-G47/G43-/G43.1
7] “Migraine headache and hormonal contraception” https://www.contemporaryobgyn.net/view/migraine-headache-and-hormonal-contraception
8] Sankaran R. Sankaran’s Schema. Homoeopathic Medical Publishers, Mumbai, India, Printed by Parksons Graphics, Reprint edition- 2014.
9] Sankaran R. Structure- Experiences with the Mineral kingdom. Homoeopathic Medical Publishers, Mumbai, India, edition- 2009.
10]Sankaran R. The soul of Remedies; Homoeopathic Medical Publishers, Mumbai, India, paperback edition- 2014.
11] Sarkar B K. Hahnemann’s Organon of Medicine. Birla Publications Pvt. Ltd. Delhi. Fourteenth edition, 2014, Pg.no-422, 427
12] Boriecke W, Dewey W. The Twelve Tissue Remedies of Schussler, Sixth edition, B Jain publications.
13] Bigal ME, Lipton RB. The prognosis of migraine. Curr Opin Neurol.2008 Jun;21[3]:301-8. doi:10.1097/WCO.0B013e328300c6f5. PMID:18451714
About the authors:
Dr Smita Balunnavar, PG Scholar, Department of Practice of Medicine, A.M. Shaikh Homoeopathic Medical College, Hospital and P.G. Research Centre, Nehru Nagar, Belagavi-590010, Karnataka.
Dr Jyothi Vijayakumar, M.D., Professor, Guide and Head of Department, Department of Practice of Medicine, A.M. Shaikh Homoeopathic Medical College, Hospital and P.G. Research Centre, Nehru Nagar, Belagavi-590010, Karnataka.
