The art of medicine is needed to prevent migraine headaches


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He spoke with an aura of superiority, in a slightly nasal voice, and his topic was migraines. It was in the late 70s, a time when there were few options to treat migraines.

“Most people who claim to have migraines just have simple tension headaches,” he scoffed. And in a move that seemed unorthodox at the time, he disclosed that he suffered from “real migraines,” so he knew all about this exclusive disease. He made it sound almost desirable by virtue of how rare it was.

At a continuing medical education course in Boston twenty-five years ago, I heard a different neurologist, this one a Dutchman, pronounce that most headaches are in fact migraines.

I recently read in The New York Times that, according to a study (published in Headache fourteen years ago) “primary care providers who diagnose a patient’s headaches as something other than migraine were usually wrong.”

The same article also points out that “sinus headaches” are not a medical reality, and are never diagnosed in Europe. Now that I think of it, I never did hear about this type of headache until I came here.

The whole notion that one explanation for a symptom is somehow more prestigious than another is bizarre, but I see this phenomenon here and there. Also, Americans seem to delight in using technical diagnostic terms instead of describing symptoms to each other or their doctors.

People come into my office all the time with “colitis,” “vertigo,” “eczema,” or “bronchitis,” not just diarrhea, dizziness, rashes or coughs. It’s like somehow they don’t need me to do anything except release my power and prescribe for the condition they already know they have. Never mind that the real explanation may be giardiasis, a cerebellar stroke, psoriasis or lung cancer.

One of the reasons for the seemingly increasing prevalence of certain disease is, of course, the drug company ads for medications that come to market for rare or previously untreatable conditions.

Ironically, as an example of that, back at Uppsala University, I remember a cursory mention of restless leg syndrome (RLS). “You can prescribe a little diazepam, that usually helps,” was the take-home message. Nobody mentioned that our own neurology professor, Karl-Axel Ekbom, who had retired he same year I started medical school, had described the syndrome, which had been alluded to by Willis in the 1600s, and nobody seemed to make much of its association with iron deficiency.

It was with the introduction of medications like Mirapex and Requip that RLS rose from obscurity to everyday parlance.

Over the past few months, I have encountered several patients who, even though they knew they had migraines, had never sought or been offered preventive treatment. There is much awareness of the many medications that treat attacks, and several of those have been cash cows for the pharmaceutical industry, whereas the preventative medications are generally old and inexpensive generics, which require patience and persistence to work.

With many diseases, and very much so with migraines, knowing the diagnosis and the names of some famous medications to treat it is not enough. How to select and titrate them is what we call the art of medicine.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

Image credit: Shutterstock.com


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