Methylphenidate for Chronic Migraine and Cluster-Type Headaches: A Case Report

Abstract

Objective: To report the successful treatment of a case of chronic, treatment-resistant migraine and cluster headaches that started after an accidental exposure to toxic gas in a patient with recurrent major depression, hypersomnia, and chronic fatigue. Case Summary: A 50-year-old female presented with a 32-year history of recurrent major depression, hypersomnia, and chronic fatigue in addition to migraine and cluster headaches that started after accidental exposure to toxic gas during an army training exercise. The frequent and severe headaches led to discharge from the army and to the patient's being fired from multiple jobs due to repeated absences. She became depressed, with hypersomnia and chronic fatigue, spending most of the day in bed for about 2 decades. This also interfered with her partner relationship. She had received tricyclic antidepressants (TCAs), anticonvulsants, triptans, migraine agents, nonsteroidal antiinflammatory drugs, and biofeedback for the headaches, all without lasting benefit. Medications for depression had included TCAs, serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors without resolution of chronic depression. Treatment for depression and fatigue began with titration of citalopram to 60 mg daily, followed by titration of bupropion SA to 300 mg in the morning and 150 mg in the afternoon. Her mood improved; however, the hypersomnia and fatigue remained along with the chronic migraine and cluster headaches. Methylphenidate immediate release was added to reduce the hypersomnia and fatigue, and her headaches markedly decreased. The patient apparently stopped taking the prescribed methylphenidate due to medication name confusion with medroxyprogesterone, and the migraine and cluster headaches returned to their prior level of severity. Methylphenidate was retitrated to 15 mg twice/day with resolution of the chronic migraine and cluster headaches, hypersomnia, and fatigue. Discussion: The literature on the use of methylphenidate, a methyl α-phenyl-2-piperidineacetate hydrochloride, for headache treatment and prophylaxis consists of 1 other case report. Methylphenidate stimulates the central nervous system, increasing norepinephrine and dopamine levels by impeding uptake and increasing release. By augmenting dopamine and norepinephrine levels in the medial prefrontal cortex and hypothalamus, methylphenidate may modulate depression and somnolence. Methylphenidate may also alter brain stem serotoninergic action, resulting in methylphenidate-mediated analgesia, perhaps modulating headache symptoms. Conclusions: Methylphenidate may have an application as a third- or fourth-tier medication for headache treatment and prophylactic action in selected treatment-resistant cases. Response appears to be dose-related.