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Headache and Chronic Pain in Primary Care

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Headache and Chronic Pain in Primary Care FAMILY PRACTICE GRAND ROUNDS Headache and Chronic Pain in Primary Care Thomas Greer, MD, MPH, Wayne Katon, MD, Noel Chrisman, PhD, Stephen Butler, MD, Dee Caplan-Tuke, MSW Seattle, W a s h in g t o n R. THOMAS GREER (Assistant Professor, Depart­ automobile accident while vacationing in another state Dment of Family Medicine): The management of pa­ and suffered multiple contusions and rib fractures. Oral tients with chronic headaches is difficult and often a source methadone had been prescribed at her second clinic visit of discord between the patient and his or her physician. when other oral narcotics failed to control her pain. She The patient with chronic headaches presented in this con­ also had a long history of visits for headaches, treated with ference illustrates most of the common problems encoun­ injections of a narcotic, usually meperidine, and oral co­ tered in the diagnosis, treatment, and management of pa­ deine. tients with other kinds of chronic pain as well. As her acute injuries healed and she was tapered off the methadone, her chronic headaches emerged as a signifi­ cant problem. Within a few months the patient was reg­ EPIDEMIOLOGY ularly requesting oral codeine for the management of her severe, intractable headaches. More than 40 million Americans consult physicians each In early September she was brought to our emergency year for complaints of headache.1 The National Ambu­ department by ambulance following an apparent seizure. latory Medical Care Survey, which gathered information Witnesses reported that the patient had “jerking move­ on approximately 90,000 patient visits to a nationally ments.” There was no incontinence; and the ambulance representative sample of physicians, determined that personnel found the patient to be irritable and disoriented headache was the second most common chronic pain but with stable vital signs. complaint.2 Back pain, headache, chest pain, abdominal Mrs. P. was admitted to University Hospital, where she pain, and knee pain made up 52 percent of chronic pain underwent an extensive workup for this apparent seizure. visits, and these problems are becoming an ever-larger The evaluation included a computed tomographic scan, portion of medical practice. The costs to society in medical spinal tap, blood chemistry determinations, and angiog­ bills, compensation payments, and loss of productivity raphy, all of which were normal. The patient was begun are enormous. The magnitude of the problem and the on phenytoin soon after admission; a subsequent outpa­ difficulty for the individual physician in dealing with it tient electroencephalogram (EEG) showed only a single are reflected in the increasing numbers of recently devel­ epileptiform discharge. oped pain clinics. While most physicians can successfully By December the patient required weekly visits and alleviate acute pain, they may use therapeutic strategies increasing medication, but showed little improvement in that perpetuate chronic pain. symptoms. A Minnesota Multiphasic Personality Inven­ tory (MMPI) showed a patient with very little insight. Our staff psychologist was consulted, and the patient was CASE PRESENTATION pressed to begin counseling. From the beginning, financial considerations were very important to the patient and her Mrs. P., a 41-year old woman, was seen at our Family family. We found a therapist with expertise in chronic Medical Center in July as a new member of a health pain at a very reasonable fee. Mrs. P. embarked on a lim­ maintenance organization. She had been injured in an ited course of therapy with Dee Caplan-Tuke, a social worker. At the same time the patient was taken off codeine Submitted, revised, August 22, 1988. and placed on a fixed-interval pain cocktail containing methadone, hydroxyzine, and acetaminophen. Among From the Departments of Family Medicine and Psychiatry, University of Wash­ other medications added were atenolol and trazodone hy­ ington School of Medicine, Seattle, Washington. Requests for reprints should ae addressed to Dr. Thomas Greer, Department of Family Medicine RF-30, Uni- drochloride; the patient was allowed to continue pheny­ versity of Washington, Seattle, WA 98195. toin and conjugated estrogen. © 1988 Appleton & Lange THE JOURNAL OF FAMILY PRACTICE, VOL. 27, NO. 5: 477-482, 1988 477 HEADACHE AND CHRONIC PAIN COUNSELING cussed at the monthly psychosocial rounds. Present be­ sides Ms. Caplan-Tuke and myself were Larry Mauksch, DEE CAPLAN-TUKE (Social Worker in Private Prac­ MEd, Family Medical Center mental health professional; tice): Mrs. P. defined as her presenting problem chronic Wayne Katon, MD, Chief, Division of Psychiatry Con­ headaches that began when she was 12 years old. She sultation-Liaison Services, Department of Psychiatry; believes that she inherited the problem from her grand­ Noel Chrisman, PhD, Anthropologist and Professor, mother and mother, who both suffered from migraines. Community Health Care Systems, School of Nursing; and Her headaches are frequent, about once a week, and in­ Stephen Butler, MD, Attending Physician, University tense, lasting three to four days. The only relief she ex­ Hospital Pain Clinic. periences is with frequent doses of acetaminophen with codeine or with narcotics injections. The treatment plan involved several aspects. The initial OTHER BIOPSYCHOSOCIAL ISSUES goal was to help Mrs. P. identify what was stressful in her life and examine how she manages stress. Her defense DR. WAYNE KATON (Chief Division o f Psychiatry against stress was to minimize it, internalize the feelings, Consultation-Liaison): First, I would like to comment on or get furious and explode. My hypothesis was that these Mrs. P.’s family of origin, which has some characteristics responses exacerbated her headaches. I began teaching that are quite common in patients with chronic pain. Mrs. her assertiveness techniques to develop some constructive P.’s father was an alcoholic who was often paranoid and alternatives to her passive-aggressive responses. The other abusive when intoxicated. He was one of seven brothers, area of treatment focused on pain management through all of whom had problems with alcohol abuse. Mrs. P.’s exercise and relaxation. The course of treatment included mother and grandmother had chronic headaches, and she individual, marital, and family therapy. After six sessions and her three sisters frequently had to take over the Mrs. P. decided to terminate counseling because of finan­ mother’s household duties when she was “ill” with a cial pressures, feeling that she could no longer afford the headache. Thus, Mrs. P. had a strong family history of treatment. Our last session was in April. both chronic pain and alcoholism, and there is a high Treatment was difficult for Mrs. P. for several reasons. familial prevalence of these problems in patients with The greatest handicap was her limited capacity for insight. chronic pain.3 Both alcoholism and somatization are cop­ She believes that a person must “pull oneself up by the ing mechanisms in which feelings are repressed and de­ bootstraps” and get on with life. She responded poorly to nied, and the patient either covers over the feelings with my efforts to help her understand the relationship between alcohol or selectively focuses on somatic concerns rather how she copes with stress and her headaches. At one point than emotion-oriented personal problems. Indeed, Mrs. she admitted that the only time she felt that she received P.’s MMPI revealed significant denial and repression of any support from her husband was when she had a head­ emotions and externalization of stress. She had a signif­ ache. He never understood, however, the secondary gains icant elevation of the hypochondriasis scale, which is cor­ resulting from her headaches. related with patients who present specific somatic com­ During the marital sessions, her husband was quiet and plaints but deny emotional or interpersonal distress. In passive. He offered verbal support but in fact spent little these patients there is a low correlation between the pres­ time at home and functioned more as an older brother ence of physical disease and self-report. Another factor than as a parent to their five boys. In the meeting after connecting alcoholism and somatization is that alcoholics our family session, however, both Mrs. P. and her husband have high rates of absenteeism in their jobs and frequently spoke of positive changes during that week, as the husband use somatic complaints as a way of hiding their addic­ was more involved with the boys and helpful to her. De­ tion.34 Thus children in these families learn early in life spite her problems and the couple’s marital difficulties, that amplification of somatic problems can be used to the boys are functioning well. manipulate interpersonal relationships as well as avoid Mrs. P.’s problems are typical of and consistent with responsibilities. substance abuse. She held firm in defining her problem A second point here is that Mrs. P. has many of the as purely physical “headaches,” categorically denying any characteristics of the adult child of an alcoholic.4 Families problems with substance abuse. Because of her belief that in which alcoholism is present often do not teach an emo­ she does not need therapy, I think that she is not a good tional language, and there is much denial and repression candidate for therapy, even if money were not a factor. I of the secret of alcoholism as well as other life problems. would recommend consideration of an inpatient sub­ The children of alcoholics often grow up fearing intimacy stance abuse program for her if the pain persists and she and dependency on another person and frequently choose does not respond to the present course of treatment. a spouse whom they will take care of as they would a DR. GREER: Several other disciplines were involved child.5 Indeed Mr. P. is a passive, dependent man whose in the care of this patient. In April the patient was dis­ parents died when he was young; and he was raised in 478 THE JOURNAL OF FAMILY PRACTICE, VOL.
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