Dustin Ouellete grew up a bit the other day.
I had known Dustin as an infant, and his mother before that. Several years ago, the Ouellete family moved away to the big city, but last summer they came back.
Dustin came in a few times with his father, and his main concern was migraines. Dustin’s father, a quiet man who seldom smiles, was concerned that the headaches were keeping his son from excelling in sports, and Dustin seemed overwhelmed with the idea of taking daily medication.
It seemed clear that physical exertion beyond a certain intensity was a trigger for Dustin’s s migraines, and at first, he thought he might be able to treat them as they came along and just be careful about learning his limits. Ibuprofen, taken early during a migraine, seemed to work three quarters of the time. The sumatriptan I had prescribed worked once and seemed ineffective another time, his father reported on the phone a few weeks after Dustin’s first visit.
I saw them in followup, and he agreed to try topiramate. During the titration period, he still had a few migraines, so I got a phone call that they were stopping it.
A short while ago. Dustin came in with his mother, an exuberant woman who used to have migraines as a teenager.
Dustin had tried out for another sport and had started to have migraines again. He had restarted the topiramate, but at 50 mg twice a day it wasn’t holding him. He was considering dropping that sport and choosing something less strenuous. His mother said “it’s up to you, Dustin”. He looked glum and overwhelmed.
I thought for a minute, then leaned back and started:
“Well, Dustin, you have a choice here. You can spend the rest of your life tiptoeing around the triggers you have for these migraines and turn away from this sport or that, or you can invest some more time and effort in finding the right dose of the medication we have started, or another one, and figure out once and for all what it’s going to take to beat this problem so you can do anything you want, maybe not this season but for the future.”
I could see his mind working.
I continued, “it’s like my right shoulder. I have dislocated it many times, but now I know exactly what I have to avoid in order for that not to happen – I can’t put my jacket on while sitting down, I can’t reach for something in the back seat while I’m driving, and so on. I decided not to have surgery, so I have to live by my limitations. That was the right decision for me, but someone with a different job might have made the opposite decision.”
Dustin sat motionless for what felt like two full minutes. Suddenly his posture changed, from a semi-slouch to bolt upright, and his eyes came alive.
“I think I’ll drop out off track this year, work my way up on the topiramate dose, see how the beginning of the summer goes just doing some informal stuff, and then be ready for soccer season.”
“You claimed it!” I made a “yes” gesture with my hand. “You stopped being a victim, you are taking charge, and not letting your migraines run your life”, I said.
Dustin almost squirmed with enthusiasm in his seat, and his mother beamed in her corner of the room.
I continued, “you can up it by 25 mg every week, I’ll send a new prescription for some 50’s, take sumatriptan if you get a migraine, and you call me when you get to 100 mg twice a day, oaky?”
“You got it!”
Dustin stood up, and his mother followed. He was taking charge.
A Country Doctor Writes: 
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