Sunday, September 28, 2014

the migraine story


Nortriptyline is very effective in the prevention of migraines, with a side effect profile that includes somnolence, constipation, and weight gain. I emailed my doctor in early May to let her know that the plan we had put in place was not working. If it was possible I was feeling even worse. She knew I didn't want to go back on prophylaxis, but wrote that she felt it was the best option to get me some relief. We agreed to a low dose of Nortripyline and I asked if I could also get a referral to the TMJ clinic.

It's hard to know where to start with this story, which is probably why it has been four months and I haven't sat down to write it. This hesitation is equal parts incredulity and a superstition that this act of writing will somehow bring the headaches back.

I've had a few dentists comment on my clicky jaw and the lack of enamel on my teeth. I've worn a night guard for years with no appreciable difference in my headaches. My current doctor had also asked me about jaw pain when we first discussed my migraines and I said I didn't think it was related. Photophobia, fonophobia, nausea, all brought on by red wine and sleep deprivation, improved with triptans - these are symptoms of migraine, not a joint disorder.

I spent my twenties ignoring the headache problem. I took a lot of Maxalt and Naprosyn and told myself there was little I could do about the headaches until I was out of training (in retrospect not entirely true but allowed me to keep drinking red wine). Although my second pregnancy was overall easier than my first, the headaches were worse the second time around. I remember making what I thought was a funny joke to a colleague that, should she ever find me yellow and confused, to start NAC (N-acetylcysteine, the antidote to Tylenol), and ask questions later. At that point I was taking up to 4 grams a day, a few times a week.  My OB had given me a prescription for Vicodin to minimize the Tylenol use. I tried it once, vomited, and went on to have one of the worst headaches of my life. When the nausea cleared, I spent the morning doing pubmed searches on the relationship between fetal heart development and NSAIDS, because really, could something OTC be so bad?  I never tried Vicodin again, but did go back to using a lot of Tylenol.

I wish I could say YOU HAVE A MAJOR PROBLEM was running through my head in illuminated scrolling letters, but it wasn't. But, if I spent my twenties ignoring the headache problem, I've spent my early thirties pretty near obsessing over it. After Wow was born, for the first time, I started doing what people who have migraines are supposed to do - pay attention. I kept a diary in the style of OPQRST pain assessment and waited for the universe to reveal what it was I should do to stop my headaches. When I could discern no pattern in onset, provocation, palliation, quality, quantity, or any other measure by which we try to understand pain, I gave up. Migraines. I get freaking Migraines was all I learned from the exercise. I saw a neurologist, read books, stopped drinking alcohol, went on stupid diets, tried propanolol, topamax, acupuncture, nasal steroids, the estrogen ring, high dose b2, magnesium supplements, amongst other methods and maneuvers well cataloged on this blog. My PCP thought I'd developed medication overuse headache (MOH) from Maxalt, so this spring I white-knuckled my way off Maxalt.  I still got headaches.

I don't remember exactly when I realized that what was once a bilateral problem had become almost exclusively unilateral, localized over my left temple with tracking back over my ear. When the pain was bad my teeth would ache. I had less light and sound sensitivity but couldn't chew gum.

Something had changed in the last few years.

I met with an oral surgeon who specialized in TMJ disorders. He asked me a lot of questions and examined my jaw. He said he wasn't sure I had migraines, or if I did they weren't causing the bulk of my current headache symptoms. I did not believe him. He gave me a few of these -
the disposable plastic tubes that fit over the water nozzle at the dentist office. He told me to place it between by molars and use it as a fulcrum to move my lower jaw forward. He told me to do this for 30 seconds, four times a day, for 4-6 weeks. He promised me I'd feel better. He also prescribed a two week course of the NSAID Mobic, which he told me was one of the few NSAIDs that actually penetrates the TMJ. I believed none of it, but smiled and agreed to the treatment plan. In the pharmacy  I picked up the Mobic, and the Nortryptline, because I was almost certain the plastic-tube-and-fancy-NSAID plan was not going to work.

I stopped getting headaches.  Well, not entirely, but very close to it. Last week I had a headache. I'd been staying up late reading Game of Thrones. On Tuesday I did a twelve mile workout with Tia and Colleen that included six 3 min hill repeats. When I got home I drank a beer and ate more chocolate than dinner. The headache I had the next morning measured squarely up as you brought that one yourself.  I also have a headache today, a low grade headache that I've had since I Friday when I got my top wisdom teeth out. Although the sockets are still oozing and the constant metallic taste of blood is making me nauseated, the surgical site isn't actually painful. What is painful is my left temple, tracking back above my ear, and so I am back to doing my little PT exercises. What I'm not getting are headaches that I couldn't have predicted.

At first I thought it was just the Mobic. I met someone who put himself into renal failure requiring dialysis and, newly aware of just how good this drug is as an anti-inflammatory,  started commenting on it whenever I saw it on a patient's medication list. Mobic, eh? followed by quick reminder that it's only for short term use. I finished the Mobic and continued doing the exercises, faithfully 4 times a day. I kept a few plastic tubes in my desk at work and in my purse. I kept waiting to start the Nortrptyline, but the random where-the-hell-did-you-come-from? headaches had stopped.

I don't think it was just TMJ the whole time. As far as I know TMJ doesn't get worse with red wine or OCPs, although I could see how it would be exacerbated by sleep deprivation and stress. There might have been a component of MOH that I beat this spring. I do understand more of my triggers now than I did in the my twenties.

I'm not sure how to end this post because I don't really feel this is over. Like I mentioned before, I've had a headache since Friday which, although provoked by dental surgery, is going a long way to dampen my optimism that the worst is really behind me. But maybe it is. And if so, this could be the last time I write about headaches.






Sunday, September 21, 2014

last day of the summer

Today, last proper day of the season, is predicted to be 90 degrees. It's been a long, dry summer, and hotter than any I can recall of my childhood. We've pulled the mattresses off the kids' beds, dragged them into our room to let the kids sleep on the floor next to a window box air conditioning unit. There aren't a lot of pools in the area, so we spent a few late weekend mornings in the municipal fountains that dot the downtown waterfront.
Munch and I read Tuck Everlasting in mid August, over a time period that contained one day of triple digit heat. I have no memory of it ever being 100 degrees here, although I'm told it has happened before. I enjoyed Tuck Everlasting, probably in no small part because weather - specifically the desiccating heat and pressurized summer storms - are so important to the story that they almost become characters themselves. And, in a bit of cosmic happenstance, we picked up the book just in time to feel as though its opening lines were speaking to us directly.

The first week of August hangs at the every top of the summer, the top of the live-long year, like the highest seat of a Ferris wheel when it pauses in its turning. The weeks that come before are only a climb from the balmy spring, and those that follow a drop to the chill of autumn, but the first week of August is motionless, and hot. 

Even when the temperature tips past 90, the mid day September sun is lower, the shadows cast longer, and the shade a bit cooler than those of July, and so we've spent as much time outside as possible in these last few weeks of summer. 



We've also been refining our indoor activities. FIL signed Munch up for "science of the month", which means once a month a package arrives on our doorstep. MIL and Munch will spend the afternoon pouring white wine vinegar into cups and watching things turn color and fizzle. We all do a lot of puzzles.
We didn't do much traveling this summer, a recent exception being a short road trip north. In Seattle we caught up with Rana and Natalie, saw the aquarium, and rode the Ferris wheel. 


We continued north to Bellingham, where easy marine access to the famed Orca pods of the San Juan Islands has resulted in many a boat tour group offering whale watching tours.

The night before our boat trip I found videos of Orcas on Youtube for the kids. In the morning a woman sitting one table over in the hotel restaurant overhead us talking about our upcoming tour and volunteered that she and her daughter had seen a huge pod of whales the day before, and by pure chance just as they were hiking along one of the more peripheral outer island coast lines. We arrived at the dock early. As we watched the staff load the boat, Munch and I took bets on who was going to see more whales that day. We were stoked.

And because I am no better than anyone else when it comes to the "active curation" of my online profile, I posted this pic on Instagram around hour five of the all-day, ultimately failed boat tour of the San Juan Islands.
Look how happy we are! Happy happy joy joy. Life with children is as ethereal as butterfly wings and as euphoric as ten thousand setting suns. 

There is one word to describe what it's like to be trapped on a boat in the middle of an endless ocean skin, never once broken by a single sea creature. It rhymes with fell.

the day's most impressive view
On the upper decks the wind whipped through our light summer clothing. Inside the cabin felt airless and stale. Only the stern, which was out of the wind and warmed by the sun, was at all pleasant. Other passengers also noticed its relative comfort and one woman spent near the entire seven hour ride chain smoking in the small, windless area. We read the kids' books twice and ran out of snacks. With two hours yet to go I bought Munch a cookie the size of her face in hopes she'd stop complaining.
LD tried to get Wow to nap.

 We took a lot of selfies.
We did not see a single whale.

Moving on.

It's been a heavy DIY summer for LD. The summer's biggest project was an 8ft long picnic table that he and my dad built for the party we held on Labor Day. The birthday party - a combined party to celebrate my dad's 64th (August 25), Tia's 32nd (August 26), and my 34th (August 27) was the largest we've hosted since our wedding.






Tia was in charge of seventy beers and veggies, my mom brought six bottles of wine and appetizers, MIL brought flowers, cheese, and kid-friendly drinks. We put out a few heavy no-cook summertime dishes alongside seventy beer-boiled bratwurst that LD served off the grill. Joan and little Lee flew out from Omaha to join a guest list that contained people from almost every stage of my life - starting with childhood, junior high, high school, college, medical school, and a few new friends since we've moved back. Tia's high school, law school, and running friends came. My dad's surf buddies came. It was my favorite party we've ever hosted.

 Weekend guests.

This blog's recent six week silence was a record in the three years since I've been blogging here regularly. I remember once listening to a would-be documentarian on TAL telling the story of the time he'd tried to capture the lives of working families with audio recordings of their every day lives. It was a project that ultimately failed because it revealed nothing novel about families like ours. There's a lot of multitasking, cut corners, and nerves made bare by sleep deprivation. There can be moments of joy, interdigitated among spates of yelling, loads of laundry, broken crayons, and potty training. I eat 70% of my calories standing up, I think in part because, for unclear reasons, just seeing their parents sit down for a meal seems has a laxative effect on both my children. There is never enough time. For anything, it seems.

I am at the end of my time for this posting. This is too bad because there were a few other recent milestones in our family.

First. I PR'ed and won my first half marathon.
(I ran 1:29:25. Yes, it was a small race)

Second - Kindergarten. A huge huge success.
Third. Stitchfix. I accumulated $75 in credit when three friends used the service through my referral link. Unfortunately the second fix was not as well chosen as the first.
I requested clothing to wear for an outdoor bbq and an upcoming trip to San Diego. I would have thought by the profile I created that it would have been clear that baggy cotton and bootcut jeans were not my style, but that's what I got. The fifth item - a chevron style maxi dress was perfect. I kept the blue and white stripped shirt only because LD liked it. In an observation that speaks volumes, he suggested it made me look "a bit softer".

Fourth. May 23rd was a big day for me. After three months of terrible migraines, I picked up this at the pharmacy-
which was to be my third attempt at prophylaxis. I also met with an oral surgeon who specializes in TMJ disorders. That was May 23. As of this writing I have not taken one tab of the Nortripyline. I am also not getting headaches.  It's a long story.

Fifth.  LD's latest DIY, a flagstone path to the kitchen door.
Sixth. Happy birthday BIL. 

welcome to the fall. 













Tuesday, August 5, 2014

cascade lakes relay 2014

The 2004 LA marathon was a misery. I'd agreed to run it with LD, but when he started walking we got into an epic fight. The story of our fight, in the water station of mile 13, would be retold time and time again, and became so well known to those around us that, a few years later, the friend who married us used the story in our wedding ceremony to illustrate the point there might be some tough times still ahead.


It had been 90 degrees and on the black asphalt heat rose in waves so thick it made the air visible. The course was along the major thoroughfares of downtown LA, without shade and crowded. I can't remember the actual words we exchanged as part of our fight, only that I had been feeling anxious before he insisted we walk and that anxiety became panic when I started to contemplate how long 13 miles of run/walk would take us. It was only late morning, the temperature was going to keep rising, and walking would prolong the time we spent exposed under the sun, I'd try to make him understand. He yelled at me to JUST GO THEN, and I took off to finish the race without him.


Although there was a band at each mile marker, the only sound I remember was of ambulance sirens as they raced up and down along the course. I didn't know it then, but Mayling was one of the runners-turned-patients who was taken off the course when her dad saw her staggering as if she was drunk. She doesn't remember her dad leading her to the sidewalk, the ride in the ambulance, or her arrival in the ED of LA County hospital. She does, however, remember waking up naked in c-booth. LAC has a massive ED (it's where the Navy trauma teams train), and c-booth is the where the most critically ill patients are assessed and stabilized (hence the "c" of "c-booth"). There are many problems with waking up naked in c-booth, not the least of which is the large deck behind c-booth where medical students and other trainees stand to look down on what's happening below. This might be considered especially distressing when one is a medical student at that institution and classmates with the some of the onlookers. 

Of the group that had run the marathon that morning - all of whom reported they'd had to adjust their expectations and performance to compensate for the temperature - the one that I could have correctly predicted to land herself in the ED with heat stroke was Mayling. She was then, and remains still, the most competitive person I've ever met. 

So when I invited her to join the our CLR team, I felt the need to be almost insultingly explicit when making the point that she could not push herself into heat stroke during this race. It was at altitude in the desert at the height of the summer heat.  We'd be exhausted, dehydrated, and operating on 1-2 hours sleep over the time period it took our team to run a total of 217 miles. There was almost zero phone reception and if she fell over in a ditch it was very likely she'd stay there. I thought about getting her a shirt that read THERE IS NO PR to remind her of this, but was certain she wouldn't wear it.

Thursday was predicted to be 100 degrees in Diamond Lake. As I packed the last of my things - including naprosyn, Maxalt, Peptol Bismol, imodium, and an outdated bottle of Cipro I'd received for a trip to Mozambique five years ago, I got a text from Tia that one of our fastest runners was out due to family emergency.  She had been assigned to our van, so on the ride south I redistributed the three extra legs amongst those of us who remained in van #2. I gave myself, Tia, and Hillary a fourth leg, and moved the longer legs to Mayling and Kelsea.  My mileage now totaled 23,  including the last leg of the race which would occur under the full measure of August's afternoon sun. 
I worried about the heat and the extra distance, about getting lost at night and my leg 36. I worried that Tia would freak when she saw I assigned her leg 32 - a mid-day 4 mile stretch with 1000 ft elevation gain. I was the only one who knew everyone else in van #2, and wondered if the different personalities would get along over the day and a half we spent living out of a minivan, without regular meals, sleep, or bathing facilities. 
the starting line, Friday morning 
I need not have worried. 







The first clue that I need not worried occurred Thursday night. We arrived at our campsite near the starting line much later than we'd planned. The sky was dark and clear and so no one bothered with the rain fly. When the first drops fell, Kelsea and Mayling rushed out of our tent to get up the fly. Tia and Hillary emerged from their own tents (both in their underwear) to help out. The only person who didn't help was me. I was wearing ear plugs and a face mask, sleeping deeply under 10 mg of Ambien and not responding to external stimuli. Luckily no one seemed terribly put out in the morning. 

And, even though we ran short of a full roster, we won. Again, which made for the team's sixth win in as many years. The team averaged 8:03 min/miles, finished 21st out of 187 total teams, and 1st in the open women's division. I ran better than last year and was very happy with the 7:09 min/mile I averaged over my 22.6 miles. 

waiting for us outside Mayling's home on our arrival late Saturday night 
But it might have been the last victory for Emily's Truckers. This was her sixth year as team captain, and she made mention that she's ready for a break. Despite the Trucker's winning streak, it was difficult to put together a team of 12.  Only 6 of last year's 12 were available, and so we all did a lot of recruiting. Last minute family emergency notwithstanding, this year pregnancies, injuries, and unexpected moves for work and school led to a rather large attrition in the weeks leading up the the race. Although we all know a lot of runners, I think it's hard to recruit for CLR because it attracts a similar type of athlete as Hood to Coast, and both races are conducted within weeks of each other.  H2C is shorter, closer to town, requires fewer provisions and overnight logistics, and is without the extremes of temperature, terrain, and altitude when compared to CLR. CLR also doesn't have H2C's non-stop party vibe, but makes up in vistas where it lacks in costumes and nudity.  

Crater Lake
(not actually on the course but twenty minutes from the start at Diamond Lake)


Diamond Lake 
And still, it isn't without its own festivity. 
Leg 33 beer run, courtesy of CLR