Best Doctors 2011: Dr. Deborah Tepper

A case I'll never forget: Unraveling the mystery behind 50 years of headaches

Theresa Bower was 72 years old and had been having headaches for 50 years. Her head throbbed. She felt nauseated and was sensitive to light, often for entire days. For about two decades, the patient woke up with a headache and went to bed with a headache, all the meanwhile taking Darvocet, Ambien and Cafergot to help with the pain.

What Theresa didn't realize, indeed what many people don't realize, is that those medications were actually making her headaches worse. They alleviate the pain initially but also cause the headaches to come back more often and even stronger. She was suffering from medication overuse headache — something that affects more than 6 million Americans and is the most common form of secondary chronic headache.

Theresa rarely got out of bed. She was sedentary. She also suffered from heart disease, and some of the painkillers she was taking for her headaches were in turn bad for her heart. Her husband thought she was suffering from the early stages of dementia because she was constantly fogged-over from the painkillers.

The night before her first visit to a special headache program at the Cleveland Clinic last February, Theresa took a proactive step and threw away all of her pain medication. Because of this, she showed up to the clinic having already vomited five times.

Now she had pain everywhere. She didn't sleep. She was stressed and anxious. I knew this was going to be a tough three weeks. I was concerned about her age and extensive medical history, but I also knew she was desperate to regain some sense of normalcy in life. She was definitely motivated, and that gave me hope.

It was amazing how being off of the painkillers just for one night improved her cognitive function. She was definitely thinking slightly more clearly than the first time I met her. That first time, Theresa's eyes were glazed over and she was a little slow cognitively. Now, I could tell she was a little sharper.

Theresa was at a crossroads. I hoped we could help her make it through that intersection.

On her first day of treatment in the program, I gave her an anti-nausea medication and Depakote, an anti-seizure medication. It decreases the excitability in the brain, calms things down. She also received a steroid to help with the inflammatory process.

The first week of this process is always the worst. We were weaning her off of drugs she had come to rely on. And this is done on an outpatient basis, so although they are at the clinic from 8:30 a.m. until 5:30 p.m., they still have to go home and try to get back to a normal routine in the evening and night.

Two days after Theresa started treatment, her husband said she was much more alert. She continued to have nausea but was sleeping six hours a night. Patients do therapy focused on particular pain areas, cardiovascular work, and strengthening with weights and bands. She found physical therapy difficult but kept at it.

Over the course of three weeks, Theresa learned how to manage emotional stress and had taken part in several family groups where we talk about how to interact with a family member who suffers from chronic headaches. She had cardio endurance training and worked on her posture. She left the program on an anti-depressant drug that also works with pain and an anti-seizure medication that is used for migraine prevention.

A colleague saw Theresa three months after she finished the program. She was continuing to have daily headaches, but they were mild. She rarely took medication for headache pain, and she hadn't had a serious migraine in that time.

Most importantly, the headaches are not interrupting her new, normal life. This is what I enjoy most about these types of cases. By the end of week three, it is rewarding to see their improvement. I also enjoy seeing how this improvement helps them interact with their loved ones. That is very satisfying.

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