Four in five migraineurs may have symptoms that announce the onset of the migraine before the headache itself. The first signs often come with a change in mood, food cravings, photosensitivity or fatigue. One in five may have additional symptoms that are more localized and last between five minutes and an hour. The most common are visual, often with shapes appearing before the eyes and enlarging – but aura can also manifest as ringing in the ears or difficulty speaking.
Could the day of man’s exhaustion be the harbinger of a migraine that never comes? The more the duo read, the more convinced they were that this is what he had. Patel did some more research and referred the patient to a headache clinic in Boston.
Part of a bigger picture
The patient was able to make his first video visit with a headache specialist two weeks later. He described his symptoms and the timeline. It starts with a feeling of malaise, he said — like coming down with something. Then after half an hour there is stiffness in his neck and shoulders, sometimes even in his jaw. Another half hour later, the weakness kicks in and he even has trouble sitting up. But he didn’t get a headache and hasn’t for decades.
The specialist had seen migraine sufferers for more than 30 years and knew that migraines came in many shapes and sizes. What the patient described was not an aura: it lasted way too long. It was as if he had a long episode of the first symptoms, but never quite got a headache. In addition, he had a history of migraine headaches, and over time, a patient’s migraines can change so that they have many of the symptoms, but not the headaches. Indeed, experts in the field no longer refer to the condition as a migraine headache, but rather migraine disease, because the headache is only part of the bigger picture. And the way these debilitating symptoms came out of nowhere and then completely disappeared was consistent with migraines.
There are no tests for migraines – it is a diagnosis that is made based on the patient’s story. The story this patient told made the diagnosis uncertain, but it was possible. To test the diagnosis, the headache specialist suggested treating the episodes with medications that can stop the progress of a migraine. A new drug, approved by the FDA just over a year earlier, called ubrogepant or Ubrelvy, had been effective for many. The drug blocks a protein that promotes inflammation in the brain that is thought to trigger the process that triggers migraines. When taken at the beginning of symptoms, it can stop the episode in its tracks. The patient did not need to be convinced. Anything that could free him from the unpredictable tyranny of these spells was worth trying.
The medication was life-changing, the patient told the specialist at the next appointment. He took it when the stiffness first started to build up, and within a few hours it was completely gone.
For decades, the presence of the typical headache has been the defining feature of migraines. Experts like the one who saw this patient now recognize that migraines can change over time, so that sometimes they aren’t even a headache anymore.
Lisa Sanders, MD, is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a resolved case to share, write to [email protected]
