Migraine affects at least 10–15 per cent of people, often starting in the teenage years, but it can come on at any time. Regularly a patient with migraine will have a family history of migraines, so that tends to make diagnosis a little easier. But for others getting a diagnosis can be tricky. Migraines might start with pains in the stomach, and some people will spend years seeing the wrong doctors. Or they may only get visual blurring with no actual headache, and so think they are going blind.
People with migraine, like with many pain syndromes, do not always get the sympathy they deserve. We cannot see or feel their pain, so ‘migraineurs’ can feel dismissed by friends and family as being feeble souls. It is very hard to explain just how disabling the headaches are, not to mention the accompanying nausea, vomiting, visual problems and the need to withdraw from the world temporarily. Patients miss work as a result and colleagues tire of having to cover for them, further undermining their self-esteem.
When I started in neurology I found my limited ability to deal with patients’ chronic headaches extremely frustrating, and what progress we made rather unrewarding. I think that is because, when you start out studying neurology as a young doctor, you focus on the more ‘exciting’ areas – movement disorders like Parkinson’s or conditions like MS – where there is a lot of novel research activity and the stakes for both patient and doctor are very high. Over 90 per cent of the headaches I diagnose are migraine, tension or medication overuse headaches, or a combination thereof, and you soon realize that, thankfully, the vast majority of the people you will see with headaches do not have a life-threatening problem.
Because headaches are so common your great fear as a doctor is that you will miss one of the potentially lethal causes of some headaches. We have been accused by media commentators and bloggers of over-investigating people with headaches, and this is probably true, but missing a diagnosis of a brain tumour or haemorrhage doesn’t bear thinking about, either for the patient or for the doctor.
Anne was in her second year in physiotherapy in college when she made an appointment to see me. She had a dry wit and she wasn’t in the least fazed by the whole ‘medical palaver’ as she called it. She had moved to Dublin a few years previously and was sharing a flat with three other young women. She described her lifestyle in hilarious detail.
She would go out at least three nights a week. These evenings would start with some ‘prinks’ (she really was getting into the Dublin lingo), consisting of either wine or gin, as Anne and her friends got ready for the night ahead. They would then go out and consume many pints, followed by shots while out clubbing until the early hours. Once in a while she would take half an ecstasy tablet – ‘Only if I was exhausted,’ she added, by way of mitigation. She would get home around two or three in the morning, and was up for college at 9 a.m.
Her diet had gone ‘pear-shaped’, she said, ‘much like myself’. She and her flatmates ordered home delivery four or five nights a week. Anne was about five foot four in height and weighed fourteen stone – she had put on three stone since starting college. Her skin had become ‘teenage’ once more, so she had been started on minocycline, an antibiotic for acne, by her GP. She was on the pill and blamed this for the weight gain, but admitted her lifestyle was probably not helping.
Anne flicked through her iPhone to show me pictures taken on her school graduation day a couple of years earlier. Though she introduced the subject, I did not comment on her weight gain. It is a minefield for a doctor when an overweight patient is in front of you. You do not want to offend them, particularly if they are already self-conscious about their size, and we have all heard horror stories of doctors jumping in with both feet and blaming all a person’s problems on their weight. Apart from being a foolish thing to do before examining a patient thoroughly, it’s not helpful to patients who are very likely to know themselves that they are carrying some excess weight. After all, Irish families don’t tend to hold back in telling loved ones – ‘for their own good’ – that they’re getting a bit heavy. So I usually ask even the biggest patients I see whether they have lost or gained any weight in the months prior to seeing me. It is lovely to see an overweight person beam with pride at this question and tell me how they have lost a few pounds. At least you know that they recognize that their weight might be a health issue and are doing something to help themselves, so it is a great starting point for helping them yourself.
Anne had started a new diet every month for the last four months, so again regaled me with bittersweet stories about her various attempts to lose weight. ‘I gave up carbs in January – I lasted two weeks. I went gluten-free, and that was easier as even Deliveroo cater for that now, but I could not resist the Sunday morning fry-ups.’ Then she listed a dizzying range of diets, many new to me – the caveman diet; the 5:2; Atkin’s (I had heard of that one) – all of which had ended in failure – ‘mostly by Wednesday evening’, she said ruefully.
At weekends she returned home to Athlone to recover from college life, bringing along a bag of laundry that her mother would have washed and ironed for her ‘little girl’ before she caught the Sunday afternoon bus back to Dublin.
‘I feel like I have two lives. At home I will go into my old routine of good food and lots of sleep, only to prepare myself for all the late nights back up in Dublin. It’s brilliant craic!’
It was when she started to notice she was hard put to read the slides during lectures that she wondered if she might have a problem. She got new glasses, which helped for a while, but she felt that the glasses then started to cause mild headaches, so she had the prescription changed. Over the next few weeks, the headaches worsened and her blurred vision became more persistent. She had started to hear strange sounds, like a tap left running; ‘My friends think I am going mad, as I keep checking the sink.’ She realized she could not put her symptoms down to her near-constant hangover any longer.
I examined her and gave her an eye test. Even with her glasses on she missed the lower lines on the chart entirely. I looked at the back of her eyes with an ophthalmoscope, which we use to examine the retinae. On each retina, the optic discs look like little saucers at the back of our eyes. With magnification, you should be able to see lots of blood vessels, like strands of spaghetti falling into the plughole of the kitchen sink. If you isolate one strand and follow it along its course, you will eventually see it disappearing down the edge of the plughole – this is the optic disc. The margins of this disc should be well defined. In Anne’s case the margins were blurred and looked swollen. The pressure in the fluid in her brain was gradually building, and this pressure had spread to the eye (optic) nerves, causing the optic discs to swell.
This pressure on the optic nerves is what was causing her blurred vision. This is called papilloedema, and is often a harbinger of serious underlying problems in the brain. Most worryingly, it can be a sign of a brain tumour; I have seen people go to their local Specsavers for a routine eye exam, only to have such papilloedema discovered. The next thing they know, they’re in Casualty waiting for their fate to be decided by a brain scan. It is very frightening for them, but thankfully the worst-case scenario does not always apply.
Anne’s weight gain, the pill, the antibiotic – all three were potentially contributing to the increased pressure in her head and causing her vision and hearing problems. If we did nothing, the pressure would continue to rise and she might go blind. It is an odd feeling sitting in front of someone as they nonchalantly crack jokes and tell tales of wild nights out while knowing that the true situation is so serious. I said only that we needed to act swiftly and organized a brain scan for later that day.
Some people with this condition – originally called ‘benign’ intracranial hypertension, until we realized that the ‘benign’ element was not always the case – have an underlying clot in the veins draining the blood back from their brain to their heart, and the ‘blocked drain’ leads to the raised pressure. Anne’s brain scan revealed no such clot, so we proceeded to a spinal tap
, or lumbar puncture.
Almost everyone I meet shudders when I mention that we will be doing a lumbar puncture. It involves lying on your side and curling into a foetal position with your back to the doctor, who cleans the area around the lower back with iodine or alcohol swabs and gives a local anaesthetic injection, like the one you get when you are having dental work. Then we place a long skinny needle into the numbed area. The patient feels pressure as we push the needle gently towards the outside part of the spinal cord.
The purpose is to get a sample of the fluid that surrounds the spinal cord, called the cerebrospinal fluid (CSF). The spinal cord and brain are bathed in this liquid, and so it is like testing the water in which our brains and nerves are ‘swimming’. Think of it as like testing the level of chlorine in a swimming pool.
It is an extremely informative test as it allows us to measure the finely tuned pressure of the fluid around the brain and spinal cord. It also allows us to test the content of the fluid and we use it to check for meningitis, bleeding in the brain and MS, among other things.
The lumbar puncture is done for many reasons, depending on the hospital department and why the patient is there. For instance, in Casualty it is often done for suspected meningitis (inflammation and infection of the covering of the brain) and encephalitis (inflammation or infection of the brain tissue itself).
The procedure generally lasts about twenty minutes, but can take longer: arthritis makes it difficult to get in between bones and ligaments that are less flexible; some people are heavier than others, and it can be difficult to get the spinal needle through fatty tissue. When a patient becomes distressed we will postpone the procedure, and rearrange it for another time (if time allows) or organize for the needle to be placed under the guidance of x-rays. Mostly there are no problems, but lumbar punctures tend to get a bad reputation online as people seem to be quick to report a bad experience but don’t bother if they have a good one.
A harder job for the doctor makes it harder still for the patient, especially when they can’t see what is being done, or even see the doctor. Occasionally the needle might touch a nerve, causing a shooting pain down the leg, which is very frightening and makes patients fear they’ll be paralysed. If I’m honest, I dread the day I’ll have one myself, but there is no getting around how essential they are as a diagnostic tool.
As Anne lay on her side, we gave the local anaesthetic. For the first time, I saw that she was afraid, and I felt so sorry for her. She was trying to be cool and brave, but suddenly this bright young woman’s jocular façade fell away. She started to cry when she recognized that there might be something seriously wrong. The nurse held her hand as we put the long needle into the space between the bones near the bottom of her spine.
It is extremely satisfying when the clear fluid suddenly starts to flow into the test tubes. With Anne, the spinal fluid shot out, and we attached a pressure monitor. Normally the pressure gauge would read less than 20 centimetres of water (the fluid flows out and climbs up the vertical monitor slowly and comes to a rest around the 15–20 mark). Anne’s fluid climbed rapidly beyond the 20 mark, then the 30 and then the 40, eventually spurting out of the top of the monitor and on to the curtains.
It was as high a reading as I had ever seen, and the fluid flowed for nearly another minute until we could see the pressure start to drop again slowly. We removed enough fluid to allow the mark to fall back below the requisite 20 mark and removed the spinal needle. Although she could not see what was happening she instantly felt better: ‘I feel clearer in my head already, less muzzy.’
I let Anne lie still for an hour and came back to see her. ‘My headache is gone!’ she exclaimed. ‘I can see properly again!’ It was remarkable; usually someone does not feel such rapid relief, so I presume there was an element of a placebo effect from the relief of not being diagnosed with a clot or a tumour and realizing that this was all very treatable.
We agreed she would do her bit to help herself and I would do mine. I gave her some medication to help keep the pressure down, but explained that it would be far more effective in the medium term if she lost some weight, gradually, and if she went off both the pill and the antibiotic.
A few months later she returned looking practically radiant. Her complexion was healthier and she had lost a stone in weight. The headaches had gone, and she no longer needed glasses. She was chuffed with herself. I checked in on ‘college life’.
‘Well, I won’t lie to you,’ she said. ‘I gave my nightclub VIP card to a friend for a while, but life goes on, doesn’t it? I have given up Jägerbombs altogether. I stay in on Mondays and Tuesdays now, but I can’t be expected to be a hermit, can I?’ She laughed. ‘And I’ve lost weight and tried to improve my diet.’
Anne was back to being the bubbly character I had first met. Soon, I hoped, she would forget the whole experience, for is that not the point of what we are doing? To return the unwell to wellness, both physically and psychologically? I wanted Anne to return to normal – and, apparently, there is no better ‘normal’ for a country girl in college than Copper Face Jack’s of a Wednesday night.
15
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LIKE FATHER, LIKE SON
Adam’s father had won a Senior Cup rugby medal in the 1970s, was a hero to his friends in the golf club and was respected in the local area. Adam had resolved he would be the same. He started running each evening, mile after mile. Initially he trained with his schoolmates every morning, and then on his own at lunchtime. He felt he needed to bulk up so he started with protein shakes twice a day, and then graduated to all sorts of supplements that the guys at the gym swore by.
The gym membership was a Christmas present from his father. Adam could see how proud his dad was when he went from playing on the third team, to the seconds and was finally on the cusp of a place on the school’s first team. He pushed himself harder at every weights session, and was more than satisfied with his progress.
On a wet Thursday evening at his weekly appraisal at the gym he and his coaches decided that he was ready to up the weights he was lifting. After the fourth or fifth attempt to lift the weights above his head, he felt a crack in his neck. He described later how something had gone ‘pop’ in his brain. He collapsed on the floor and was lucky the weights did not fall on top of him. He lost consciousness briefly. He woke on the ground, with his friends looking down at him. He got up slowly and felt a wave of dizziness, so sat down again quickly. He was embarrassed but insisted he was OK – ‘just a bit light-headed’. But something told him that all was not well.
In spite of his worries, he was acutely aware of not showing weakness – one of the players from the Cup team had been prohibited from playing for the rest of the season after being knocked out in a practice session a few weeks earlier. So Adam put on a brave face and told the others that he hadn’t eaten earlier – ‘probably just low blood sugar’, he said. He went for a walk on his own and felt better quickly.
Ignoring the coaches’ advice to take it easy for a while, within the hour he started lifting some lighter weights. No problem there, so he pushed on. When he got to the machine where he had collapsed earlier, he was nervous but eased into it. As he relaxed, his competitive instinct kicked in. He was close to the higher weight again when he began to feel it. As he strained, he felt a sharp pain at the top of his head. He panicked, and dropped the weights. He stood up quickly, but collapsed again.
His friends were really concerned now, but he assured them he was fine and that he had just overdone it. He showered and left the gym, hoping against hope that his friends would keep quiet about the episodes. He felt fine by the time he got home, but homework was out of the question as he couldn’t concentrate, so he went to bed early. The next morning he woke up feeling fine. He went to the bathroom, and after a few minutes in the shower a niggling pain in the base of his skull made itself felt. It got progressively worse, and by the time he had dressed he had an excruciating headache.
‘Oh God,’ he thought,
‘I’ve burst a blood vessel in my head. I won’t be able to play.’ He lay down on his bed and was relieved to feel the headache dissipating. He told himself that he was overreacting and just needed to calm down. When the pain had subsided he decided he had better get going or he would miss pre-school rugby training. He stood up nervously, but he was fine. Yet by the time he was on the bus the pain had started to return. In the changing room his head was pounding and he felt dizzy again. He had to tell someone. His coach asked if he’d been out the night before. When Adam said no, the session was cancelled and his coach drove him to Casualty.
We arranged an MRI scan during which the scanning process was halted briefly and dye was injected into Adam’s veins. The beautiful pictures of Adam’s brain showed that there was no tumour, no bleeding and no inflammation, but the covering of the brain and spinal cord – the meninges – lit up after the dye was injected.
Adam had a low-pressure headache – the opposite of Anne’s high-pressure. When he had strained himself lifting the heavier weights, he had torn a tiny hole in the meninges. The brain is like an orange – the fruit is the brain itself and the meninges is like the peel that forms a protective covering (membrane) around the precious tissue. The cerebrospinal fluid lies between the fruit and the peel and acts to bathe the brain and spinal cord and helps protect against external stresses to our skulls. When we do a lumbar puncture, as with Anne, we sample the fluid between the meninges and the brain/spinal cord. We then take the needle out and leave a tiny hole in the protective covering that seals up quickly in most people. In others, like a stubborn nick of the razor when shaving, the injury refuses to heal and the spinal fluid can continue to leak out. If it does, the patient will get an almighty headache whenever they sit up which is relieved only by lying flat. This can go on for days or even weeks.
Just One More Question Page 10