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CASE HISTORY:

A 59 year-old female presents to the emergency department acutely ill and functionally incapacitated. Her chief complaint is several days of severe nausea, persistent visual changes she describes as if seeing 'heat radiating off of a hot car', dizziness, a generalized and severe sensitivity to sound, light, and odors, and mild background headache. Her examination is normal, including a CT of the head.

The patient has a thirteen year history of visual disturbances- 'like seeing zig-zag lines', at times associated with headache-mild to severe. Over time the visual disturbances and associated headache progressed in frequency and duration, until at the time of her admission to the emergency department these occurred daily.

The patient was diagnosed with chronic migraine that transformed into 'status migraine' (severe, persistent migraine symptoms lasting more than three days duration) that resulted in her admission.

She was treated and discharged in good condition.

Migraine is a term commonly used by patients and doctors alike to describe headache of a certain type.

Therein lies a major dilemma because 'migraine', the disorder,  can be the correct diagnosis for symptoms not involving headache at all, and the complaint of headache can often be a result of causes arising outside of the head.

The distinctions are important to understand if you want to get the right diagnosis and the right treatment.

Headache, particularly severe or persistent headache, is a common reason people visit the doctor.  If you go to the doctor with the complaint of headache there is a very good chance you doctor will shut down his (when I say 'his' I mean 'her, as well) thinking cap and only consider things in and around the head that can create head pain. Many causes of the complaint 'headache', however, arise from outside of the head, including depression, hypertension, and many others.

Good doctors make what is called in the 'doc biz' a differential diagnosis', something I've mentioned before in my postings.  In the case of headache the differential diagnosis would be a list of all possible causes of headache which list is then used to derive the actual cause (diagnosis) of your headache. That's what good doctors would do.

But, what if you complained of generally not feeling well, fatigue, weakness, visual changes including light sensitivity, blind-spots,or blurred vision, increased sensitivity to sounds and odors, irritability, abdominal pain, nausea, and more, but no headache. Would your doctor consider the diagnosis of migraine? He should, and now so should you.

All of these symptoms can be the result of what is called 'migraine', just not 'migraine headache'.  People who experience these symptoms, with or without the classic signs of migraine headache are called migraineurs ( mig'-gra-nurs or my'-grain-urs).

You see, migraine is a chemical disorder of the brain that can affect all parts of the body.

There have been some recent and amazing, and not so amazing, but important, discoveries about migraine that you should know about.

Here are some.

Migraine is now considered a chronic disorder with episodic, or periodic, attacks of headache or facial pain with or without any of the other symptoms I mentioned above..

Migraine can also be the correct diagnosis in patients with the generalized complaints I mentioned above, but with no headache.

Migraine is now considered a progressive disorder where the spells come more frequently and the symptoms more severe.

Migraine can have destructive effects on peoples lives, including disruption of work, careers, relationships, and more. This feature of migraine needs to be stressed because most doctors, and patients do not recognize the progressive, erosive effects that migraine can bring over time and which needs to be understood for proper treatment.

There are specific medications called 'triptans' that treat the chemical cause of migraine and the symptoms that you take just when you think you are about to get or just getting a migraine spell, not afterwards. This is called 'early intervention'.  Recently, the FDA approved the combination of sumitptan (Imitrex)and naproxen (like Aleve) for this purpose.

Here is a list of some 'triptans:

• Axert
• Frova
• Imitrex
• Maxalt
• Relpax
• Treximet
• Zomig

Keep in mind these are not pain medicines, which are generally to be avoided in treating headache.  Also, any one of the 'triptans' may work well and have no side effects, while the others will not work or bother you. Experimenting is the key to success.

There are many, many, medicines that can prevent migraines from occurring. These you take every day to prevent the migraine from occurring in the first place. These include;

• Calcium Channel Blockers such as Verapamil
• Beta Blockers such as Inderal
• SSRI drugs such as Paxil, and the like
• Tricyclic drugs such as Pamelor, and the like.
• Anti-Seizure drugs such as Topimax

You may need one or more of these to prevent your migraines.  They, like all drugs have potential benefits and risks that have to be weighed against each other in your individual case.

PRACTICE HEALTH DEFENSE:

Know what migraine is.

Know that only about half of patients with migraine are correctly diagnosed.

If you think you may have migraine suggest the diagnosis to your doctor or see a neurologist with an interest in headache.

If you have headaches, or migraines, DO NOT SEE A 'PAIN DOCTOR'. Pain doctors generally treat pain with pain medicines no matter the cause of your pain. You always need a diagnosis and a treatment specific to that diagnosis, not medicines to mask the symptoms. Pain doctors can be of help in certain specific circumstances when the diagnosis is clear and treatment options are gone, but, they are few.

Taking pain medicines on a regular basis can CAUSE headache and should be avoided.  These include the OTC drugs such as Tylenol, Advil, Aleve, and others.

Be wary of self-treating headache.  There are many causes of headache, some of which may be life threatening. 

If you are not getting good results from your primary-care doctor see a neurologist with a special interest in headache.