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When Migraine Is Treated Like a Zebra Among the Horses

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One of the first lessons a medical student often learns is, “When you hear hoofbeats, think horses, not zebras.” This metaphor when applied to medicine means that if all of the symptoms fit a particular diagnosis, it is most likely the diagnosis. A physician won’t think an individual has an aneurysm when they have symptoms of the common cold. So, why do we treat a migraine as a symptom of a greater problem that can never be found?

Before a physician can treat an illness, they must make a diagnosis. The process of making a definitive diagnosis is referred to as differential diagnosis. A physician takes a medical history and rules out diseases according to test results and assessments they conduct. There is one trend I have noticed when going through the differential diagnosis having migraine. Most of the physicians I have seen treated migraine as a symptom rather than a diagnosis of its own. They treated migraine like a glorified headache that was “causing” another problem. All of the other symptoms of migraine were tossed aside as if lightheadedness, vision changes, fatigue, word-finding difficulties, and spasms did not equate to migraine. It was as if I was using the word headache as a synonym for a migraine attack as far as any of them were concerned.

Migraine was a symptom of a greater unknown problem until proven otherwise, and I did not agree with the approach. Not one of these doctors considered the complexity of migraine as a neurological disease. Not one considered all of the symptoms that are experienced during a migraine attack. Not one of them spoke up to say my case was out of their area of expertise. Not one of them recognized the diagnosis of migraine was made by a neurologist and not Google. Most importantly, not one of them considered the limited knowledge we have as both a medical community and society about this complex neurological disease. All they did was keep testing.

As I was seeing each one of these doctors, they talked to me about the “cause” of migraine. Each one asked me what lifestyle choice was “causing” migraine. I listened as different individuals tried to suggest my triggers were responsible for the biological changes in my brain. Imagine, barometric pressure, altitude, food additives like MSG, and sleep changes were all the “cause” of migraine. This is not the case; each one of these things can increase the likelihood a migraine attack will occur, but they are not responsible for the biological changes that are experienced in the brain.

In short, migraine is not solely the result of an individual’s choices. Migraine is a physiological change that is believed to be genetic, but we do not know the extent of the cause of migraine right now. What was clear at that time is that many specialists gave up when the cause of the single symptom (headache) could not be determined. However, we know a migraine is anything but just a headache.

The field of neurology is rather amazing. Cardiologists, orthopedists, and other specialists cannot directly interact with the organs they specialize in. By interacting, a neurologist knows what their chosen organ is thinking, feeling, and doing. They get immediate feedback because they are trained to look for it. A neurologist is not the one who was too afraid to be a neurosurgeon. They were the one willing to challenge the abnormalities of the brain and treat them.

It is probably shocking for many to find out there are not enough doctors that specialize in migraine. According to information gathered from the Migraine World Summit, “There are 520 neurologists who specialize in migraine for 37,0000 people diagnosed with migraine.” With that kind of knowledge, no wonder no one really understands migraine. No wonder we still do not know where migraine comes from, and how to cure it.

I do not know where migraine research is headed. I do not know when we will find a cure. There are a few things I have learned from my diagnosis. I know migraine is a real neurological disease. I know there are only so many things I can do to manage attacks as they come. I know migraine is a complex combination of symptoms and not just a headache. I know others diagnosed battle the same stigmas I do. And if we could just start by recognizing migraine as a real diagnosis, with head pain being one symptom, maybe we would make some progress toward acceptance. Will migraine continue to be a zebra, or when you hear hoof beats, will you think of a horse?

Originally published: October 27, 2017
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