Day: March 28, 2020

A migraine is not “just a headache.”

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The audacity of some people! To call a migraine just a headache is almost a type of blasphemy. Millions of people suffer from debilitating migraines every year. Just like fibromyalgia and other conditions that have no outwardly visible effects, it is difficult for people to understand just how awful they are. Let me enlighten you.

A migraine is a type of vascular headache that causes severe throbbing pain or a pulsing sensation, often on one side of the head. The headache often comes with nausea, vomiting, and photophobia and phonophobia (sensitivity to light and sound). An attack can last for hours to days in some cases. The symptoms can be so severe that they can completely shut a person down for days. No garden variety simple headache can do that. This is why a migraine episode is often referred to as a migraine attack. It literally feels like you are under attack.

Let’s go through the possible stages of a migraine attack. The four stages are prodrome, aura, attack and post-drome.

Prodrome occurs one or two days before a migraine. Consider it like a sort of heads up or warning that a migraine is coming. Some symptoms you might experience are constipation, mood changes( depression to euphoria), food cravings, neck stiffness, increased thirst and urination, and frequent yawning.

Aura is something that might happen before or even during a migraine. The symptoms of an aura are reversible neurological symptoms. Usually they are visual symptoms like seeing various shapes, seeing bright spots, seeing flashes of light, loss of vision or tunnel vision. Sometimes a person feels pins and needles in an arm or leg. Sometimes there is weakness or numbness in the face or one side of the body. Some people get aphasia or difficulty speaking. Some people hear noises or music and have uncontrollable jerking or other body movements. Most often these symptoms appear and develop gradually and last for 20 to 60 minutes before the actual headache begins. These symptoms can be truly terrifying, especially if the person does not realize they are about to suffer from a migraine. Think about it. what actually differentiates these symptoms from possible stroke symptoms for example? Yup! Scary stuff. I can remember my first migraine at age 18. I was in college. I can remember suddenly losing vision in my left eye, tingling in my arm and then I had trouble speaking. I could not find a word to say my life without a struggle, if at all. I remember trying to call my mother and not actually being able to speak, which just terrified the both of us. My friends dragged me to the ER, but by the time I got seen several hours later( apparently an 18 year old with stroke symptoms was not concerning), the symptoms were gone and they sent me home…without any real information or guidance. This is how it goes for many patients during their first migraine attack.

The attack of headache itself usually lasts from four to 72 hours if untreated. During the attack, patient feels pain in one or both sides of the head. It usually throbs or pulses. There is intense sensitivity to light and sound. Aaaand let’s not forget nausea and vomiting. Only the best for migraine sufferers

The post drome consists of fatigue and feeling drained and even confused for up to a day. Your head feels sore almost. Even the slightest movement can bring the pain back. It is sometimes referred to as the migraine hangover.

So, we just finished talking about all the phases and the similarity to stroke symptoms. How do you know when to take it more seriously and see a doctor? Obviously, it is a good idea to see a doctor if you are experiencing chronic headaches with any kind of symptoms, just to be safe. When you go to the doctor, it is a great idea to keep a headache diary of all your episodes and symptoms and any triggers you have been able to determine. This will help the doctor get your diagnosis established more quickly and get you the help that you need that much sooner.

You should also see a doctor or go to the ER right away if you have any of the following symptoms: 1) An abrupt, severe headache almost light a thunderclap in your head, 2) A headache accompanied by fever, stiff neck, seizures, mental confusion, double vision, weakness, numbness or trouble speaking, 3) A headache or worsening headache after a head injury, 4) A chronic headache that is worse after coughing or straining or sudden movement, 5) A brain new kind of headache after the age of 50. Yes, there are some of these symptoms that can also occur with a migraine as well, so it can still be confusing. I would say err on the side of caution whenever your symptoms seem new or not consistent with your usual migraine. If you’re wrong, great. It’s a migraine only. If you are not wrong and you ignore it, you could actually be suffering from a stroke, meningitis, a brain tumor, a hematoma or worse.

So, what causes migraines? They aren’t fully understood yet, but we think that genetics and environmental factors might play a role. Researchers have studies changes in the brainstem and it’s interactions with the trigeminal nerve. The trigeminal nerve is a major pain pathway in the body. The trigeminal nerve is also called the fifth cranial nerve. It has branches that go along the temple, along the cheek, and along the jaw line. It is responsible for sensation int he face and motor functions like biting and chewing. Researchers are also studying the role of serotonin imbalances in migraine sufferers. This make sense since serotonin helps regulate pain in the nervous system. They are also lookig at the role of other neurotransmitters like calcitonin gene-related peptide. Stay tuned!

Now let’s look at some migraine triggers. These are just some common ones. They can be different for everybody. Hormonal changes in women are a trigger, especially fluctuations in estrogen before, during or after menses, pregnancy, and menopause. This is where that migraine diary I was referring to earlier comes in very handy. This type of migraine is sometimes referred to as a menstrual migraine because of it’s relationship to hormone changes. Sometimes oral contraceptives or hormone replacement therapy can make migraines worse. There is also some data that suggests that combined oral contraceptives and hormone replacement therapy may not be a good idea in migraine patients anyway because of possible stroke risk. There is other data that suggests hormone modulation may be very helpful. Other times women say that they feel better on these medications. There is not really a good way to determine ahead of time which group your patient will be in. There is some trial and error involved. Having said that, and just to add to the confusion, one of the best treatments that I have found for menstrual migraines is to have a patient put on an estrogen patch two days before their anticipated menses and wear it for several days into their period until the usual point when symptoms would resolve on their own. I have found that, in the right patient, I can eliminate the menstrual migraine almost immediately.

Other possible migraine triggers are drinks that contain alcohol, wine, and too much caffeine. Since migraines are vascular headaches, they may be triggered by things that affect our vasculature. Alcohol causes vasodilation ( dilation of blood vessels) . Caffeine causes vasoconstriction ( stricture of blood vessels). Interestingly, caffeine can become kind of a vicious cycle in migraine patients because it can sometimes ward off a headache in the early stages….and then it can also cause both migraines and caffeine withdrawal headaches. Caffeine is a tricky one. I try to counsel my patients to avoid it all together in the first place if possible. Remember that caffeine is found is several different sources: pop, coffee, chocolate, tea, and dairy products with added sweetener.

Stress is definitely a migraine trigger. This refers to any kind of stress at home or at work. Even stress from illness can trigger migraines. This is why it is important for migraine patients to discover stress relief techniques that work for them.

Sensory stimuli can be migraine triggers. Bright lights, sun glare, and loud sounds can trigger migraines. Strong smells like perfume, paint thinner, second hand smoke and others can trigger migraines. At our office, we have a scent free policy for all patients and vendors. People who show up with any kind of strong scent will be rescheduled. We have too many employees, myself included, that will be down for the count if they smell the wrong thing and then everybody will have to be rescheduled anyway. I wish people wouldn’t fight it so much. You don’t need to take a bath in perfume and then go to the doctor. I won’t be offended if you don’t smell like flowers, cakes, or pie. I promise!

Sleep changes can trigger migraines. Sleep changes refer to insufficient sleep, interrupted sleep, or jet lag

There are certain physical factors that can trigger migraines. Intense physical exertion can trigger migraines in some people. There is a phenomenon called post-climactic migraine as well. Some unfortunate patients get migraines immediately after sexual climax. Talk about unfair!

Weather changes that cause a change in barometric pressure can also cause migraines. This seems to be particularly evident with big changes in temperature or sudden changes like a storm that brews up quickly.

We talked about oral contraceptives and migraines earlier. Essentially, any medications that cause vasodilation can also trigger migraines. This includes medications like nitroglycerin, minoxidil, ACE inhibitors and hydralazine.

Certain foods can possibly trigger migraines like aged cheese, salt, or processed foods. Ironically, most of my migraine patients crave these exact foods. Remember when I talked earlier about cravings preceding a migraine? I think this relationship needs further exploration. I think it is possible, at least with regard to the cheese, that eating it might trigger some sort of histamine release since it is made of mold, almost like an allergic response. Histamine release can cause vasodilation and vasodilation can trigger migraines. This is just my theory at this point. Certain food additives like aspartame and MSG can also trigger migraines. I can image that it is because these additives also have salt. High levels of salt impair the function of the endothelium (lining of the wall) in our blood vessels. Once again, anything that affects the blood vessels can trigger migraines.

What are some risk factors for developing migraines? Family history is one. If you have a family member that gets migraines, you are more at risk for developing them too. Have we found the migraine gene yet? No. But, I am willing to bet that we will some day. Age is a factor as well. Most migraines begin in adolescence, seem to peak in the 30s and then slowly become less severe. This is not true for all patients however. Mine took a turn for the worse not the better in perimenopause, but then seem to be settling down again. Being female seems to be a risk factor for migraines. women are three times more likely to have migraines than men. I am assuming that is related to the whole fluctuating hormones issue.

Now lets talk about how to diagnose a migraine. For the most part, it consists of ruling out everything else. You go to see a doctor specializing in headaches, usually a neurologist. They take your history, family history, mediation history, etc and do a neurological exam. If everything they find is consistent with migraines, they diagnose you with migraines. If you have any unusual symptoms like I listed earlier, they may order an MRI or a CT scan to rule out other serious conditions like stroke, tumor, multiple sclerosis, etc.

What are some treatment options for migraines? They basically fall into two categories: non medication and medication therapies. A migraine diary is essential as the first component to pinpointing effective treatment. It can help to identify triggers and patterns. The first thing that I do with patients is to talk about trigger avoidance and lifestyle changes like avoiding caffeine and getting good sleep, etc. Some of my patients have also benefited from other options like acupuncture and cranio-sacral therapy. These methods are controversial to say the least. However, I am of the opinion that, if an option has not been shown to be harmful, you bet I am going to offer it to a patient.

There are migraine medications available as well. They can basically be divided into two categories: pain relief and prevention. The pain relief drugs are taken during attacks and help stop symptoms. the preventative medications are taking regularly, often on a daily basis to reduce the frequency and severity of migraines.

The pain reliever options fall into seven main options: straight pain relievers, triptans, dihydroergotamines, Reyvow, Ubrelvy, opioids, and anti-nausea drugs.

1) Straight pain relievers are over the counter or prescription medications like aspirin, ibuprofen or Excedrin. You have to be careful and not take these for a prolonged period of time because they can cause other problems like medication overuse headaches, ulcers and gastrointestinal bleeding.

2) Triptans are another category of medications that block pain pathways in the brain. They bind directly to 5ht1D/1B receptors in the intracranial vessels in the brain. They come in pills, nasal sprays, or shots. They are most effective when taken immediately upon onset of prodrome or attack. These are meds like Imitrex, Tosymra, and Maxalt. They may not be safe to use in patients who are at risk for stroke or heart attack.

3) Dihydroergotamines like D.H.E or Migranal are another category of medications. These medications are migraine-specific serotonin agonists that bind to multiple receptors in the brain. Remember how we talked about how important serotonin is in pain perception and transmission? These are most effective when taken shortly after start of symptoms for migraines that tend to last over 24 hours. They can have unpleasant side effects like worsening of migraine-induced vomiting and nausea. They come in nasal spray or injection. Just like triptans, they should be avoided in people with coronary artery disease, high blood pressure, kidney disease, or liver disease.

4) Lasmiditan(Reyvow) is in its own category. It binds to a different serotonin receptor in the brain, 5HT-1F. The exact mechanism is not known, but we assume it has an agonist effect. It is approved for migraine with or without aura. So far it has been great for improving pain, nausea, and sensitivity to light and sound. It is also unique because it is an oral medication. Patients have to be extra careful with this medication because it can cause drowsiness and sleepiness. It also shouldn’t be taken with alcohol or other central nervous system depressants.

5) Ubrogepant(Ubrelvy) is also in its own category. This is an oral calcitonin gene-related peptide antagonist. It is approved for acute migraine with or without aura in adults. It is the first drug of it’s type. So far it is very effective in reducing nausea, pain, and sensitivity to light and sound within two hours. Side effects include nausea, excessive sleepiness, and dry mouth. You cannot take Ubrelvy is you take other CYP3A4 inhibitor drugs like amiodarone ( blood pressure med), itaconazole ( anti-fungal), and clarithromycin (antibiotic).

6) Opioid medications are another category. Some people cannot take other migraine medications as we already discussed because of other medications or health conditions. These address pain only and have the side effects of drowsiness and are highly addictive. They should only be used if there is no other alternative.

7) Anti-nausea drugs are the last category. These are usually taken in combination with pain control medications and can help with nausea and vomiting. These are medicine like Reglan, Compro, Zofran, and Chlorpromazine.

Preventative medications fall into five main categories: blood pressure-lowering medications, antidepressants, anti-seizure drugs, botox, and calcitonin gene-related peptide monoclonal antibodies.

  1. Blood pressure-lowering medications include beta blockers like propranolol and metoprolol. They also include calcium channel blockers like verapamil. These are good at preventing migraine with aura. Side effects include drowsiness, dizziness, dry mouth, and cold hands
  2. Antidepressants are another category. Tricyclic antidepressants like amitryptiline ( Elavil) are good in treating chronic pain and are good in preventing migraine by increasing serotonin levels which then constricts intracranial blood vessels and helps stop a migraine from starting. The side effects include sleepiness and weight gain however.
  3. Anti-seizure drugs are another category. Migraine activity in the brain has been compared to seizure activity so it makes sense that anti-seizure meds could be helpful. Topamax and Depakote have been used. There are significant side effects with these medications like dizziness, weight changes, nausea, psychosis, etc. They can also cause seizures during the weaning process if a patient decides to go off of them. They are definitely not my favorite first line option.
  4. Botox injections are yet another category. Botox can be injected every 12 weeks in the areas around the eyes, nose, forehead and neck. This is successful in preventing migraines in some patients. Let’s remember that Botox comes from botulinum toxin, a toxin that causes flaccid paralysis and death. In the proper hands, it can causes minute, targeted, temporary relaxation in the desired muscles. In the wrong hands, side effects could be very serious.
  5. Last but not least comes the potential holy grail trio of medication options,: the calcitonin gene-related peptide monoclonal antibodies. This group of drugs include Almovig, Ajovy, and Emgality. They are all available in monthly injection. So far, they have been nothing short of amazing in patients with chronic migraine. I have had patients with daily migraines for years reduced to none at all! These medications have truly been lifesavers so far. So far, the most common side effect has been a possible reaction at the injection site. The only drawback at this point that I can appreciate is their considerable expense to the patient and the sometimes lengthy prior authorization process. Unfortunately, that always seems to be the case with a newer medication that is truly effective.

Last but not least, let’s talk about some alternative medicine options for migraines. Acupuncture is one option that we talked about earlier already. Biofeedback also seems to be effective in relieving migraine pain. It teaches the patient how to monitor and control certain involuntary physical responses ( like muscle clenching) to negative stimuli. The negative responses are monitored and the patient is taught how to recognize them and reverse them. There is some argument for cognitive behavioral therapy as well. This type of therapy teaches patients how behaviors and thoughts affect how they perceive pain. Herbs ,vitamins and minerals also play a role in migraine prevention and symptom reduction. Feverfew has been shown to potentially prevent migraines. Butterbur was recommended in the past, but now not so much because of safety concerns. Vitamin B2 (riboflavin)may be helpful in migration prevention and severity. There is some possible data on Coenzyme Q10, but more information is needed. Some research suggests that magnesium levels are low in migraine patients so magnesium supplements have been tried. The results are mixed so far.

Well, that was probably more than you ever wanted to know about migraines. I am sure there is a lot more to know in the future, but that’s all I have for now. I hope this was helpful and that you are now convinced that a migraine is not “just a headache.”

Dr. Katz

Fibromyalgia is a real pain in my…..everything!

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Ah fibromyalgia! So often maligned as a bullshit, all in your head disease. Patients are placated, symptoms downplayed as just being overemotional or “making yourself sick” or dismissed all together. Seeing is believing when it comes to diseases right? If you can’t see anything on the outside of a person, they must be OK right? Wrong! Did you know that some physicians feel so strongly that fibromyalgia is baloney that they will refuse to see patients that have that on their history list. How do I know? Because I am one of them!

Ok, now that I am semi-finished with that initial rant, let me educate you a bit about fibromyalgia. I feel like it is time, as I am sitting here in full flare, probably brought on by the itty bitty amount of stress around me in the world today…lol

Let’s start out with some diagrams about fibromyalgia and all that it affects

Now let’s talk about fibromyalgia. We are not going to be able to discuss everything in the diagrams above, but we are going to hit some of the key points. The following information regarding fibromyalgia comes from a mix of two sources: my own experience and the Mayo Clinic. I figured that it would probably mean more to pull out a big gun like the mayo to help convince the dubious of this crappy disease’s validity. Well, here goes. Fibromyalgia is a real beast. Did you know that fibromyalgia is one of the most common chronic pain conditions in the world. It affects about 10 million people in the United States alone, according to the National Fibromyalgia Association. It is a disorder that is characterized by widespread musculoskeletal pain and fatigue. It does not cause joint damage per say, but the musculoskeletal pain is still quite severe. It also affects sleep, memory and mood. YAY! There is research that suggests that fibromyalgia amplifies painful sensations by affecting the way the brain processes pain signals. Huh? What? For example, a typical person might find light stroking on their arm(“arm tickles”) pleasurable on any given day. For a person with fibromyalgia on a flare day, they might perceive those light arm tickles as a person literally digging into their arm with hot pokers, which is about the furthest from a pleasurable sensation that you can get. This can definitely get in the way of a good episode of hugging or snuggling.

So, why does it hurt? We think that this abnormal processing of pain signals in fibromyalgia patients is due to abnormal levels of the neurotransmitters in the brain, spinal cord, and nerves. We have seen that repeated nerve stimulation in fibromyalgia patients actually causes changes in the brain and abnormally increases these neurotransmitters. On top of that, the pain receptors in the brains of fibromyalgia patients then go on to develop a type of pain memory and become even more sensitive. This results in the receptor “overreacting” to any pain signals.

We really do not know for sure what causes fibromyalgia. It is said that fibromyalgia symptoms can begin after a physical trauma, surgery, infection or significant psychological stress. However, there are other patients with fibromyalgia that gradually develop symptoms over time with no triggering event. Family history also seems to play a role in fibromyalgia. A patient is more likely to develop fibromyalgia if they have a relative who has it. I have seen this myself over the years. In my particular case, I can check off several of those boxes. I am blessed to have survived some horrendous car accidents. I have experienced lifetime movie-worthy psychological stress, in addition to multiple surgeries and I have family members who suffer from fibromyalgia.

The part about the correlation to psychological stress is what really gives fibromyalgia a bad name and it’s victims a lot of discrimination. This fact just makes it easier for people to label those patients as psychosomatic or treat them as if their pain is not real. Trust me the pain is real! The flares are real! I am very fortunate that I do not get flares that often, but when I do, I experience a multitude of symptoms including diffuse hot pain, especially in my neck, back and shoulders. All my sensations are off. I could scratch an itch on my arm and swear I just accidentally burned myself with a hot drill. My head hurts. I feel feverish. I am exhausted. Sometimes I even feel dizzy. My TMJ acts up. I get temporary irritable bowel symptoms. It just really adds up to a super fun day. I will admit that there is a correlation between stress, emotions, and symptoms. The symptoms are definitely worse when I am stressed, but then sometimes I have symptoms even when there is no stress and then I become stressed out because I feel so shitty. It can really be a vicious cycle. I am not sure that anyone can truly understand what a person with fibromyalgia goes through unless they have actually experienced it. We tend to judge people and their disease severity by outward appearances. It’s like we can’t believe something is real until we can “see it with our own eyes.” Well folks, there is nothing to see here and I guarantee you it is very real!

Let’s break down these symptoms a bit more: widespread pain, fatigue, and cognitive difficulties. Fibromyalgia pain is often described as constant dull aching that has lasted at least intermittently for at least three months. It has to occur on both sides of your body and above and below your waist to be considered widespread. As far as fatigue, fibromyalgia patients often wake up exhausted, no matter how long they have slept. Their sleep is often interrupted by pain and other sleep disorders like restless leg syndrome and sleep apnea, just to add to the fun. “Fibro fog” is a term that is used to describe the cognitive troubles like impaired ability to focus, pay attention and concentrate. I get it, fibro fog sounds made up, but it is very real as well. There are times when my level of discomfort really does get in the way of finishing a thought at that moment.

Fibromyalgia likes to hang out with a multitude of other painful diseases like migraines, irritable bowel syndrome, migraines and other headaches, interstitial cystitis( painful bladder syndrome) and TMJ. It’s almost as if all the fibromyalgia components aren’t enough by themselves. It’s like a domino effect with other body systems falling in line with altered pain perception with emotional component. The patients that have more than one of these pain syndromes truly have the capacity to suffer without some compassionate help.

Did you know that women are more likely to develop fibromyalgia than men? According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, women are eight to nine times more likely than men to have fibromyalgia. It has been suggested that women could be more at risk for fibromyalgia in part due to the role that hormones play in the perception of pain. Fluctuating estrogen and progesterone levels during the menstrual cycle seem to correlate with severity of fibromyalgia symptoms in some women. This fact of course leads to more discrimination as women are often thought of as the more emotional sex to begin with. This is consistent with the misguided thinking that fibromyalgia ORIGINATES from emotions and emotional triggers rather than the more accurate fibromyalgia is AFFECTED by or ACCELERATED by emotional triggers. There is a difference.

How is fibromyalgia diagnosed? Back in the good old days, doctors would put a patient through an 18 point pain exam. This exam consisted of a physician pressing firmly on 18 different points on a person’s body to see if any of them were painful. Nowadays we do not put patients through the tender point exam. Now doctors diagnose fibromyalgia based on the patient’s symptoms and if a person has had widespread pain( both sides of the body and above and below the waist) for more than three months with no underlying medical condition that also causes pain. There are no specific blood tests or x rays to diagnose fibromyalgia. But, doctors will probably draw a complete bood count, sed rate, ccp, rheumatoid factor and thyroid function tests to rule out other underlying disease.

So, how do we treat it? Is there any hope? The best option for fibromyalgia treatment is a combination of medication and self care. I am a fan of the multidisclipinary approach, emphasizing good physical and mental heath, along with management of pain to increase quality of life. As far as medications, the U.S Food and Drug Administration has approved three drugs for the treatment of fibromyalgia. Two of these drugs alter serotinin and norepinephrine levels to help control pain: Cymbalta and Savella. There are some older drugs that affect these same neurotransmitters as well like Elavil and Flexeril that can also be helpful. The third drug approved to treat fibromyalgia is Lyrica. Lyrica works by blocking the overactivity of nerve cells that are involved in the transmission of pain. Neurontin works in a similar way and is also sometimes used. Over the counter pain relievers like Tylenol, Motrin, and Alleve can also be helpful. Narcotics and opioids are not a good idea for fibromyalgia because they can lead to dependence and even worsen pain over time a a result. In addition, the side effect of sleepiness would only accentuate the baseline fatigue that fibromyalgia patients already suffer with.

There are non drug therapies as well. Physical exercise is the most effective treatment for fibromyalgia and should be used in addition to any drug therapy. Patients benefit the most from regular aerobic exercise or other body-based therapies like Tai Chi and yoga. Let me be clear, I am not saying anything about it being EASY to exercise with fibromyalgia. More often than not, I am usually cursing like a sailor when I first get started, especially if I am having a bad day and am hurting. The good news is that, even if a patient is in pain, low impact physical exercise will not cause any harm. I have to admit that, even if I am hurting at first, I usually feel better when I am done and I definitely feel better day to day if I keep up an exercise regimen. Physical therapy is also a good option because the therapist can individualize exercises for strength, flexibility and stamina. Water based exercises are very helpful as well. My motto is it’s ok to keep cursing, as long as you keep moving.

Acupuncture has also been suggested as an option for Fibromyalgia. Acupuncture involves the insertion of very thin needles through your skin at particular points on your body. It has been a key component of Chinese medicine for thousands of years. The Chinese use it to balance the flow of energy or life force (chi) that flows through the meridians( pathways) in your body. They believe that inserting these needles will re-balance the energy flow. In Western medicine, the acupuncture points are viewed as places to stimulate nerves, muscles and connective tissue. By stimulating these points, your body’s natural painkillers are stimulated like substance P, endorphins, and met-enkephalin. This stimulation of natural painkillers can possibly help with fibromyalgia pain.

The S.H.I.N.E protocol has also been suggested as a holistic approach to treating fibromyalgia and chronic fatigue syndrome. S stands for sleep. Get adequate sleep to replenish your energy and muscle repair. H stands for hormones. Correct any underlying hormone imbalances such as estrogen, progesterone, testosterone, or thyroid hormones. I stands for immunity and infections. Looks for underlying viral, bacterial, bowel, sinus or yeast infections and treat them. N stands for nutrition. Make sure that your vitamins and minerals are in optimal balance. E stands for exercise as able. Don’t overdo it and cause undue fatigue. Gradually increase exercise as tolerable.

It is very important to keep yourself mentally healthy with fibromyalgia. All that pain can really drag you down. Patients with fibromyalgia have a high percentage of anxiety and depression. Some of them had anxiety and depression before developing fibromyalgia. Some develop anxiety and depression after fibromyalgia. I think that chicken or the egg question can never be answered with certainty. I always recommend regular counselling to my fibromyalgia patients and I use it myself as well. A counsellor can be a fabulous resource for stress management strategies which can help lessen flares. In addition, a counsellor can help get at the root of any psychological trauma the patient may not have processed yet.

Last, but not least, I think it is important with fibromyalgia to take an active hand in developing your own strategy for how to deal with flares, keep moving and increase your own quality of life. I have noticed over the years that the biggest predictor of quality of life in my fibromyalgia patients is whether the patient is actively seeking ways to feel better and be captain of their own ship or if they have given up, resigned to be a victim forever. I have some patients who are in a wheel chair and on disability and I have some patients, like myself, who are active with jobs and living their lives. I really do believe that there is a mental game that must be played and won with fibromyalgia in order to not let it rule your life. I know that for myself, I have to get up every day and will myself to keep plugging and keep going, even if I don’t feel like it. I am not successful every time. There are some days when I am having a flare that is so ridiculous that I have to stay home, drink tons of water and wear an ice helmet around my head and neck. I have to force myself to go for a walk or workout because I don’t always feel like it and it hurts when I do it sometimes, but I know it is essential to keeping me moving I have to come up with ways to manage pain that still allow me to function during the day. My favorite pain management so far is to use some daily turmeric as a supplement, do some kind of workout every day, use Motrin when I have to, and drink tons of water to help me clear whatever inflammatory lactic acid that I have built up in my muscles. Massage is great too, when I can get to an appointment. I try to manage stress the best that I can, but I would be lying to say that I am perfect at it. Stress is unavoidable in my line of work…and life..lol The point is, that I have developed some strategies that are working for me..most of the time. Everybody is different. This disease sucks, but it is not life-threatening. We need to own it and work hard to find whatever strategy works for us. You are not going to cure it, but you need to find a way to live with it. That’s all for now.

Dr. Katz