A 50-year-old African-American veteran with a history of PTSD and severe recurrent major depressive disorder (MDD) presented to the psychiatric emergency room with complaints of suicidal ideation and exacerbation of traumatic reexperiencing in the form of flashbacks of dismembered body parts witnessed during his experience in the first Gulf War. The patient was diagnosed with PTSD and MDD nine years after his traumatic experience. He had suffered from flashbacks, nightmares, avoidance of memories, avoidance of military personnel who reminded him of the event, insomnia, and hyperstartle. In addition, he had prolonged periods of depressed mood, anhedonia, feelings of worthlessness, and psychomotor retardation. These symptoms of depression had predated his military experience. He also had periods of suicidal ideation since his military service; however, he had never attempted suicide. The patient also reported waxing-waning headaches that began three years prior to this emergency room presentation. He reported that his flashbacks, nightmares, and suicidal thoughts worsened during these headaches. The patient's traumatic exposure did not include a head injury. The patient had not been directly exposed to any concussive blasts, had no history of loss of consciousness, and denied any other history of head injuries. He did not meet criteria for traumatic brain injury.
The patient was admitted for inpatient psychiatric treatment, which included continuing his outpatient medications of citalopram 40
mg for treatment of MDD and PTSD and prazosin 5
mg for PTSD-associated nightmares. The patient had been taking acetaminophen and gabapentin for headaches. These were discontinued upon admission because the patient reported no pain relief from these medications. The patient was changed to ibuprofen 800
mg as needed for headaches. During the first week of hospitalization, the patient spent most of his days fully submerged under bedcovers in his room. He wanted limited interaction with other veterans as they reminded him of his traumatic experience. He complained of daily headaches and reported exacerbation of the headache with light and noise; the ibuprofen contributed minimally to palliation.
The ibuprofen was tapered and then discontinued because of concern for nonsteroidal anti-inflammatory drug (NSAID) rebound. He was started on sumatriptan because of the medical team's presumption that the patient may be having migraines. The patient showed no relief with sumitriptan. Further discussion with the patient revealed that his headaches had been constant for greater than eight months, were localized to the left side, and associated with left-sided rhinorrhea and lacrimation. At the beginning of the third week of hospitalization, the patient's headache was discussed with a neurology consultant who recommended trying high-flow oxygen or indomethacin. The neurology consultant suggested inclusion of hemicrania continua in the differential diagnosis. The patient was given a 15-minute trial of oxygen at eight liters per minute.
The patient reported that the headache abated significantly within two minutes of oxygen treatment and did not recur. By the next morning he reported significant improvement in his depression and PTSD symptoms, which had been recalcitrant over the prior three weeks. The patient was discharged after three weeks of hospitalization with no headache and significant improvement in his depression and reexperiencing symptoms.
The patient returned to the psychiatric emergency room one week later reporting that the headache had recurred, and he was having traumatic reexperiencing of “bodies, blood, and horror. For three days, I was doing good, but then I just became depressed again and had the nightmares of dead bodies.” The patient was then started on indomethacin 25
mg three times daily. After one day of indomethacin, the patient reported abatement of the headache. He remained pain-free for an additional week on indomethacin. Moreover, the patient reported that his depression and PTSD symptoms were well controlled when the headaches were treated.
Unfortunately, the patient did not adhere to the indomethacin regimen after discharge. He reappeared in the psychiatric emergency department two months after discharge reporting that the headaches had recurred and increased in intensity over the past three weeks. He said that his nightmares, depressed mood, and suicidal thoughts crescendoed with the increasing headache intensity. He was treated again with high-flow oxygen and indomethacin, which abated the headache. He was discharged after a three-day inpatient hospitalization. The course of the patient's headaches and psychiatric symptoms after that hospitalization are not known.