A migraine without a headache? Isn't that kind of like fat-free half and half? Isn't a headache what a migraine is?
That's what my patient Lisa thought until just a few weeks ago. A busy mom in her 40s, Lisa has had migraines occasionally for many years. These have been very predictable. If she drinks too much coffee, or becomes dehydrated, she sees sparkly lights in her right field of vision and then gets horrific, throbbing pain in one side of her head, often with nausea and vomiting.
Not long ago, Lisa had symptoms that were, ultimately, also attributed to migraine, but which felt nothing like what she'd experienced before. First of all, she hadn't drunk too much coffee and she wasn't dehydrated. It started with some subtle and disturbing word-finding difficulties. She would say something to her husband, but the right words didn't come out. This happened a few times over a couple of days. Then, at work, she had the sensation of a shade being drawn over her right eye. In fact, she asked a co-worker if she'd turned the lights down. Then, her right shoulder began to tingle. At this point she came to the hospital and was admitted for a neurological evaluation. She was diagnosed with migraine--and she had no headache at all during the entire episode.
Migraine is a very common disorder, frequently running in families and affecting women more often than men (probably because of women's cycling hormone levels). It has long been thought due to dilation and constriction of blood vessels in the brain, though newer theories implicate dysfunction in serotonin and other neurotransmitters, irritability of nerve cells, and other factors. About a third of people have what's called an aura, a visual disturbance (like Lisa's sparkly lights), smell, or other sensation that signals a headache is coming. Then, in its most typical form, a migraine starts on one side of the head (the word "migraine" is a shortened version of "hemi-cranium" or "half-skull"), often behind one eye. The pain may spread, and nausea and vomiting can occur. Lying down in a dark room, sleeping, and taking medications such as caffeine, aspirin, ibuprofen, or triptans (Imitrex, Zomig) finally bring relief.
But some people don't have typical migraines. They may have prolonged or clustered headaches, or they may not have a headache at all. Sometimes called "silent migraine" (or "acephalic migraine"), these attacks may involve partial loss of vision or hearing, focal weakness or numbness, or difficulty speaking, such as Lisa had. These symptoms are terrifying and, if the patient has never had them before, a stroke, brain tumor, multiple sclerosis and other serious conditions need to be ruled out.
Writer Joan Didion is a long-time migraine sufferer (in fact, she weighed in on whether Michele Bachmann's migraines would affect her candidacy for the presidency--remember that controversy last summer?) I have always loved Didion's essay "In Bed"about her migraines, especially the last line, about how she feels when a migraine is finally over:
I open the windows and feel the air, eat gratefully, sleep well. I notice the particular nature of a flower in a glass on the stair landing. I count my blessings.
I am sure any migraine sufferer can relate to this. I imagine that for someone like Lisa, who experiences a frightening "silent migraine," the feeling of relief when it's over must be even greater.
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