Addiction & Substance Abuse
"Compulsive urge to use substances despite knowing the harm they cause"
What is Chronic Migraine?
Addiction/Substance Abuse is a chronic, relapsing brain disorder characterized by compulsive drug seeking and use despite harmful consequences. It involves dysregulation of the mesolimbic dopamine pathway, impaired prefrontal cortex function, altered reward circuitry, and persistent changes in neurotransmitter systems including dopamine, glutamate, and GABA. Common substances include alcohol, opioids, stimulants, benzodiazepines, cannabis, and nicotine.
Healthy Function
What your body should do
A healthy reward system involves the ventral tegmental area releasing dopamine into the nucleus accumbens in response to natural rewards (food, social connection, achievement). The prefrontal cortex exercises executive control over impulsive drives, allowing for decision-making, delay of gratification, and behavioral inhibition. The extended amygdala regulates stress responses and provides balance to the reward system. Healthy neurotransmitter function includes adequate dopamine for motivation and reward, GABA for calming effects, and glutamate for cognitive function, all working in concert to maintain behavioral balance.
When Things Go Wrong
Signs of chronification
- Pain threshold lowers over time
- More frequent attacks
- Brain stays in alert mode
- Medication stops working
How This Develops
Understanding the biological mechanisms helps us target the root cause
Point 1
Understanding the mechanism helps us target the root cause rather than just treating symptoms.
Recognizing All Symptoms
Chronic migraine affects multiple systems. Understanding your symptoms helps us identify the underlying mechanisms.
Physical Symptoms
13 symptoms
- Tolerance: needing more to achieve same effect
- Withdrawal symptoms when stopping (tremors, sweating, nausea, vomiting)
- Physical deterioration: weight changes, poor hygiene
- Insomnia or hypersomnia
- Chronic fatigue and low energy
- Headaches and dizziness
- Gastrointestinal problems (nausea, constipation, diarrhea)
- Respiratory problems (if smoking substances)
- Cardiovascular issues (palpitations, high blood pressure)
- Neurological symptoms (numbness, tingling, seizures in withdrawal)
- Signs of injection: needle marks, skin infections
- Alcohol-specific: flushed face, slurred speech, unsteady gait
- Opioid-specific: constricted pupils, drowsiness, itching
Cognitive Symptoms
10 symptoms
- Preoccupation with obtaining and using substances
- Cravings that feel overwhelming
- Difficulty with decision-making and planning
- Impaired judgment and risk-taking
- Memory problems and blackouts
- Difficulty concentrating
- Denial about the extent of the problem
- Rationalization and minimization of use
- Obsessive thinking about next use
- Difficulty learning from negative consequences
Emotional Symptoms
10 symptoms
- Mood swings and emotional instability
- Anxiety, especially during withdrawal
- Depression, often co-occurring
- Irritability and anger
- Feelings of shame and guilt
- Low self-esteem
- Numbness or emotional blunting
- Hopelessness and despair
- Social isolation and relationship conflicts
- Defensiveness when confronted about use
Metabolic Symptoms
9 symptoms
- Weight loss or gain depending on substance
- Nutritional deficiencies
- Dehydration
- Electrolyte imbalances
- Blood sugar dysregulation
- Liver dysfunction
- Kidney stress
- Compromised immune function
- Hormonal imbalances (testosterone, cortisol)
Conditions That Occur Together
These conditions often coexist with chronic migraine due to shared mechanisms
Depression
Bidirectional relationship; 30-50% of substance use disorder patients have comorbid depression; self-medication hypothesis; shared neurobiology involving dopamine and serotonin systems
Anxiety Disorders
High comorbidity rates (40-60%); alcohol often used for self-medication; benzodiazepine withdrawal mimics anxiety; shared genetic and environmental risk factors
Post-Traumatic Stress Disorder (PTSD)
Trauma often precedes and maintains addiction; 50% of PTSD patients meet criteria for substance use disorder; self-medication to numb traumatic memories
Chronic Pain
Opioid prescriptions for pain led to epidemic; chronic pain patients develop dependence; bidirectional relationship between pain and substance use
Sleep Disorders
Alcohol disrupts sleep architecture; withdrawal causes insomnia; sleep disturbance increases relapse risk; common in early recovery
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD increases vulnerability to substance use 2-3x; stimulant medications can be misused; dopamine dysregulation common to both conditions
Gastrointestinal Disorders
Alcohol causes gastritis, ulcers, pancreatitis; opioids cause constipation; gut-brain axis involvement in cravings
Liver Disease
Alcoholic hepatitis, cirrhosis; also affects metabolism of substances and medications; contributes to cognitive impairment
Cardiovascular Disease
Stimulant use causes hypertension, arrhythmias; alcohol can cause cardiomyopathy; IV use risk of endocarditis
Conditions to Rule Out
These conditions can present similarly but have distinct features
Substance Use Disorder (SUD)
Impaired control, social impairment, risky use, tolerance, withdrawal
DSM-5 criteria require 2+ of 11 criteria within 12-month period; severity graded as mild (2-3), moderate (4-5), or severe (6+)
Dependence (Physical)
Tolerance, withdrawal
Physical dependence can occur without addiction (e.g., certain medications); characterized by physiological adaptation, not necessarily compulsive use
Abuse (Substance Abuse)
Risky use, failure to fulfill roles
Pre-DSM-5 term; did not include tolerance and withdrawal; replaced by SUD which captures more nuanced presentation
Addiction (Behavioral)
Compulsive behaviors, loss of control
Term often used interchangeably with SUD; behavioral addictions (gambling, internet) lack substance involvement but similar neurobiology
Relapse
Return to use after abstinence
Part of chronic disease model; not a treatment failure but a temporary setback requiring recommencement of treatment
Tolerance
Need for more substance
Physiological adaptation; can develop without dependence or addiction; common with many medications
Withdrawal
Physical symptoms upon cessation
Physiological response to cessation; varies by substance; can be medically managed; does not equal addiction
Pseudo-addiction
Drug-seeking behavior
Behavior driven by uncontrolled pain, not euphoria; resolves with adequate pain management
What's Driving Your Migraines
Identifying the underlying causes allows us to target treatment effectively
Genetic Predisposition
40-60% - Family history increases risk 2-4x; specific genes affect dopamine signaling (DRD2, DRD4), alcohol metabolism (ADH1B, ALDH2), and reward sensitivityFamily history assessment; genetic testing for risk variants; adoption studies confirm genetic contribution
Early Exposure
30% - Adolescent brain particularly vulnerable; early use increases addiction risk 2-3x; prefrontal development disruptedAge of first use; developmental history; assess brain development impact
Chronic Stress
35% - Stress increases substance use motivation; elevates CRF and drives negative reinforcement cycleStress history; ACE score; cortisol testing; life events assessment
Trauma
40% - Adverse childhood experiences strongly predict addiction; trauma drives self-medicationTrauma history; ACE questionnaire; PTSD screening
Mental Health Conditions
50% - Comorbid psychiatric disorders increase addiction risk; self-medication hypothesisComprehensive psychiatric evaluation; assess for depression, anxiety, ADHD, PTSD
Social Environment
30% - Peer influence; availability; social norms around use; family patternsSocial history; peer network assessment; family history of use
Reward Sensitivity
25% - Variable dopamine system sensitivity; high reward sensitivity increases vulnerabilityBehavioral assessments; personal history of reward-seeking behaviors
Impaired Executive Function
30% - Prefrontal cortex deficits affect impulse control, decision-makingNeuropsychological testing; assess for ADHD; decision-making assessments
Chronic Pain
20% - Pain-driven opioid use; pain patients vulnerable to dependencePain history; opioid prescription history; alternative pain management assessment
Key Laboratory Markers
These biomarkers help us understand your specific migraine mechanisms
What Happens If Left Untreated
Understanding the consequences helps you make informed decisions about your health
Physical Health Deterioration
Months to yearsOrgan damage (liver, heart, brain); increased infection risk; neurological damage; cancer risk; premature death (average lifespan reduction 10-20 years)
Mental Health worsening
Immediate and progressiveComorbid depression and anxiety worsen; increased suicide risk (10-20x higher); cognitive decline; emotional numbing
Relationships and Family Destruction
ProgressiveBroken marriages; estrangement from children; lost friendships; family trauma passed to next generation
Occupational and Financial Collapse
Often within monthsJob loss; bankruptcy; legal problems; homelessness; inability to maintain basic responsibilities
Legal Consequences
VariableDUI arrests; drug possession charges; incarceration; criminal record affecting employment
Overdose and Death
UnpredictableOpioid overdoses killed 80,000+ in US in 2021; Fentanyl contamination increasingly common; risk highest during relapse after tolerance reduction
Secondary Health Conditions
YearsHIV/Hepatitis from IV use; TB; pneumonia; cardiovascular disease; cancers linked to substance use
Quality of Life Annihilation
Immediate and progressiveComplete loss of meaningful life; isolation; shame; hopelessness; existential suffering
Time Matters
Don't wait for symptoms to worsen. Early intervention leads to better outcomes.
How is Chronic Migraine Diagnosed?
Comprehensive evaluation to identify triggers, contributing factors, and appropriate treatment
Comprehensive Addiction Assessment
Purpose:
Establish diagnosis and severity
DSM-5 criteria fulfillment; substance use history; consequences; readiness to change
Urine Drug Screen
Purpose:
Detect recent substance use
Opioids, amphetamines, cocaine, benzodiazepines, cannabis, barbiturates, metabolites
Blood Alcohol Level / Breathalyzer
Purpose:
Assess current intoxication
Blood alcohol concentration; recent use
Liver Function Tests
Purpose:
Assess alcohol impact on liver
GGT, AST, ALT, bilirubin; markers of alcoholic hepatitis, cirrhosis
Complete Blood Count
Purpose:
Assess overall health
MCV (macrocytosis), anemia, infection, immune function
Comprehensive Metabolic Panel
Purpose:
Assess organ function and electrolytes
Kidney function, electrolytes, blood sugar, liver function
Lipid Panel
Purpose:
Assess cardiovascular risk
Cholesterol, triglycerides; alcohol affects lipid metabolism
Infectious Disease Screening
Purpose:
Screen for bloodborne pathogens
HIV, Hepatitis B and C
Nutritional Assessment
Purpose:
Identify deficiencies
Vitamin B12, folate, magnesium, iron studies
Cardiac Biomarkers
Purpose:
Assess cardiovascular impact
For stimulant and alcohol use; troponin, ECG if indicated
Psychiatric Evaluation
Purpose:
Assess co-occurring disorders
Depression, anxiety, PTSD, ADHD screening; severity ratings
Neuropsychological Testing
Purpose:
Assess cognitive function
Executive function, memory, attention; frontal lobe assessment
Our Integrative Approach
A comprehensive, phased approach to treat chronic migraine at its source
Comprehensive evaluation and medical stabilization
Comprehensive evaluation and medical stabilization
Complete addiction assessment using DSM-5 criteria,Medical evaluation and laboratory testing,Psychiatric evaluation for co-occurring disorders,Safe detoxification if medically indicated,Medication-assisted treatment initiation if appropriate,Motivational interviewing to enhance readiness,Establish therapeutic alliance,Assess social support and resources
Medical stabilization and withdrawal management
Medical stabilization and withdrawal management
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Address underlying issues and build recovery skills
Address underlying issues and build recovery skills
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Consolidate gains and prevent relapse
Consolidate gains and prevent relapse
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Maintain sobriety and optimize quality of life
Maintain sobriety and optimize quality of life
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Prevent relapse and thrive
Prevent relapse and thrive
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Supporting Your Treatment
Evidence-based lifestyle modifications to enhance treatment effectiveness
What Success Looks Like
Complete abstinence from all substances of choice
No cravings or minimal manageable cravings
Restored physical health (normal labs, improved functioning)
Stable mood without substance-related mood disruption
Improved relationships and social functioning
Returned occupational/educational functioning
Legal issues resolved
Financial stability restored
Quality of life measures improved
Sustained engagement in recovery activities
Ability to handle stressors without substance use
Meaningful life goals being pursued
Frequently Asked Questions
Ready to Find Relief from Chronic Migraines?
Our integrative approach has helped hundreds of patients find lasting relief from chronic migraines. Schedule your comprehensive assessment today.