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Ellen is a 48-year-old elementary teacher with a history of migraine dating back to her twenties. She is perimenopausal with hot flashes and fatigue, and a recent increase in migraine frequency to 5-6 headaches per month. Her family physician diagnosed depression two years ago and started Ellen on a trial of sertraline.
She is referred to you after a recent fall with head trauma that resulted in mild confusion for one hour but no loss of consciousness. An MRI showed >20 white-matter lesions, including 10 periventricular, seven juxtacortical and three infratentorial lesions suggestive of MS. Ellen reports no symptoms suggestive of optic neuritis, myelitis or infratentorial syndrome. However, she has noticed increasing fatigue, ‘cog fog’ and depressed mood over the past two years, which she attributes to being perimenopausal. She says she has been less active lately and has gained about 7 kg over the past two years.