Since you asked, Anonymous…

For the record: no, technical error has not been ruled out as a possible origin vis a vis my brain’s Blue Screen of Death. It hasn’t been ruled out for a couple reasons, not the least of which is the fact that it’s physically impossible to survive as long as I did with no detectable brain function. No, really, it’s not possible, regardless of what Congressional representatives who should have their medical licences suspended for diagnosing outside their specialty on the basis of a video tape would like you to believe. It is rendered even more impossible by the fact that there was no meaningful disruption in my body’s autonomic biological functions — I didn’t stop breathing, my heart kept beating, despite the DWI displaying complete brain-stem dysfunction. If my brain had shut down and then I’d coded and required resuscitation, well, that would have been normal. Bad and serious but normal. Nor is this a case of Lazarus Syndrome, which is medically defined as the spontaneous autoresuscitation after failed CPR, in which pulse and respiration restart themselves in patients who have been declared clinically dead, usually some minutes or hours later, and which is usually followed close on by dying again, permanently, because the brain is not intended to go without oxygen for long periods of time.

EDIT: As of 5ish 1/28, no technical error to account for what is now being described as a “highly anomalous” DWI result. None of the other tests done with that particular machine on that day or in the days preceding/following are showing any pattern of wildly divergent results and a mechanical examination declared the machine itself basically free of defects. The official determination — “highly anomalous DWI result” — is basically High Doctorese for “we don’t even freaking know/man that’s weird/can we poke your brain some more?” I have approximately forty million appointments over the next couple weeks with assorted neurologists, at least one of whom is a specialist in the neurology of migraine development and who is very freaking much looking forward to meeting me, I assure you.

I’m going to digress a little bit at this point and talk about migraine headaches — more specifically, my migraine headaches, because every migraineur is just a trifle different from every other migraineur, even though we’ve all got many things in common.

First things first — what migraines are not. Migraines are not “just a bad headache.” Every time I see some dipstick on the internet making this assertion and mocking people for failing to “take an aspirin and get over it,” I am smitten with the ardent wish that I’d gone to school to obtain the technical knowledge required to reach through the computerized ether and punch such people in the face. With an axe. Because that might serve as the ultimate explanation for exactly how it really feels to have a migraine. Nor are migraines “just a woman/a woman on the rag thing.” Nor are migraines an indicator of mental illness/mental retardation. These things are pernicious myths that make people like me wish serious physical and mental harm of those who promote and disseminate them. Okay, maybe not all people like me, because I’ve got this propensity for responding very, very badly to stupidity. But I’m willing to bet that a large cross-section of all migraineurs got tired of being told to suck it up and deal by people who’ve never in their lives dealt at all a long damn time ago. It gets wearying.

Second things — what migraines are.

Migraine headaches are, in technical terms, an idiopathic chronic neurological disorder. Idiopathic does not have anything to do with “idiocy” but actually means arising spontaneously or from an obscure or unknown cause. With the rapid expansion of medical diagnostic technology and sophistication in the 20th and 21st centuries, there are actually very few diseases remaining that are legitimately considered idiopathic any longer, and a few are crossed off the list every year as causes previously undetectable or misunderstood are identified and clarified. Migraines, however, still are in large part because there exists no single, or even multiple, smoking-gun causes/sources that apply consistently across a large enough cross-section of migraineurs to say, with absolute certainty, “this is why your headaches happen.” They are chronic, which means they’re long lasting and recurring. Risk factors are linked to genetics (upwards of 90% of migraineurs have a family history of the disease — my biological mother had migraines, as does one of my great-uncles, and so do several of my cousins), age (most begin experiencing migraines in adolescence though some start earlier), biological sex (women are three times as likely as men to suffer from migraine headaches, though boys are likelier to start having migraines earlier, in pre-adolescence), and hormonal changes (the “rag-induced headache” you see people snarking about can be and frequently is a migraine, which can be triggered by both the hormonal changes of the adolescent body and the hormonal changes of menstruation). They have triggers, much like allergens, that can cause an attack to occur or be more likely to occur if a migraineur is exposed to them and almost everyone’s triggers are different and wildly variable in sensitivity. And since there’s no known singular cause, there’s also no cure, only treatment and management.

So, what happens during a migraine?

There are several different theories. The most medically well-supported is that brain chemical imbalances cause a change in the activity of the brainstem and its interactions with the trigeminal nerve, causing the release of chemicals called neuropeptides. The neuropeptides flood the meninges, triggering widespread vasodilation of the meningal blood vessels, serotonin uptake inhibition, autonomic nervous system involvement, and quite a lot of really moderate-to-severe and biologically unregulated pain. This can occur over a longish period of time, in a series of phases, or quickly and all at once — I’ve experienced both kinds and neither is what can be described as “fun.”

The occurance of a “phased” migraine follows this general pattern: prodrome, aura, the actual headache, and postdrome. Even so, not every migraineur follows this pattern or experiences all aspects of this pattern. I personally, typically have all four stages, so that’s what I’ll talk about next.

Prodrome is a medical term used to describe the precursor symptoms of a disease that manifest prior to the activation of the disease itself. For a generalized example: feeling tired or headachy or not having an appetite just before you really get hammered by a sinus infection or the flu. That “I’m getting sick” feeling is prodrome for infectious diseases. For migraineurs, prodrome can start a day or two before the actual headache itself hits and the vast majority of migraineurs experience precursor symptoms, a great many of them linked to the alterations in brain chemistry we experience during the lead up to a migraine. My own most common prodrome symptom is the fatigue/depression/sleepiness trifecta — and by that, I mean when I’m in prodrome it’s way beyond ordinary day-to-day tiredness and well into the land of watch Dr. Harada become an utterly sessile mass that could not be asked to get out of bed if a smoke alarm is going off. Really. When I was in college I had to be physically removed from bed by my roommate and a residence associate during a fire drill because I was deep in prodrome and I absolutely could not work up any desire to even begin to think about moving. The hyperactive prodrome I experienced before going over to John Q’s House of WTF is almost entirely alien to my adult experience of my condition, though my Dad tells me that my early childhood prodrome symptoms tended to involve being insanely hyper and highly irritable. A great many of the common prodrome symptoms — fatigue, depression, hyperactivity, irritability, mood swings, euphoria — are also symptoms of serotonin deficiency, which occurs during migraines, and others — such as a stiff neck, parasthesia in the hands and face, cravings for sweets/salty foods, assorted digestion upsets — are symptomatic of autonomic nervous system involvement triggered by irritation of the trigeminal nucleus. The vast majority of migraineurs experience prodrome of some variety — it’s a major self-diagnostic method for incipient migraine in sufferers, our friends and family — and the symptoms can start anywhere from days to hours in advance.

Aura is probably the thing most people who’ve never had a migraine have at least heard of before in relation to the condition. “Aura” is the medical term used to describe the neurological phenomena that occur immediately prior to/in conjunction with the migraine itself. The most well-known examples of migraine aura are the visual phenomena — scotomata (blind spots, larger and more physically visible than the naturally occurring blind spot in human vision), scintillating scotomata (flashes of colored light that may or may not arrange themselves into patterns — these are also called fortification spectra or teichopsia, because of their resemblance to physical structures like castle walls and battlements), hemianopsia (partial loss of vision in one or both eyes), photopsia (flashes of black and white light), tunnel vision. Some people experience complete, temporary blindness in one or both eyes during particularly severe auras and the accompanying migraine. Relatively decent examples of what these effects look like can be found here:

Simulations from YouTube:

These effects are all medically classified as hallucinations and they’re generally understood as being caused by the hyper-excited neurological activity that precedes an actual migraine attack. Simply put: a migraineur’s brain freaks out and the retinal nerves interpret that freakout in ways that would probably be a lot more entertaining if they were achieved with recreational chemicals and weren’t followed immediately by skull-cracking pain. Other fun aura related hallucinations are olfactory (phantom smells) and gustatory (phantom tastes), neither of which I’ve personally experienced, though I have a friend who now associates the flavor of Lemon Heads with her migraines, and auditory (phantom sounds), which I have occasionally experienced. Particularly severe auras can produce parasthesia in the hands, arms, face, lips, and tongue, usually on the side of the head that you’re about the experience the migraine, temporary dysphasia (inability to properly speak, read, or write), vertigo, numbness in the extremities, or, alternatively, extreme sensitivity to touch. Point in fact, severe migraine aura and migraines themselves can mimic stroke symptoms to such a degree that misdiagnosis is entirely possible. That being said, the vast majority of migraineurs do not actually experience any form of aura at all, and those that do are prone to growing out of it as they get older — the peak of migraines preceded by aura is statistically about the age of 4 to 5. Most never experience aura at all, some get to have the joy their whole lives. Guess which one of those I am?

There aren’t any visual aids to help describe the headache itself unless I were to ask one of Rin’s friends to get fancy with the Photoshop or possibly to link you to this article from the New York times:

In a more clinical and less artistic description, a migraine is a headache generally characterized by unilateral (one side of the head, either front or back, left or right) moderate-to-severe pain with a throbbing, pulsating quality (think a strobe light made of pure agony), compounded by sensitivity to light, sound, smells, and physical movement, and with the side-effects of nausea/vomiting, blurred/temporarily occluded vision, and lightheadedness/fainting. Sometimes a migraine starts out unilateral and becomes bilateral during the course, sometimes it starts and stays bilateral, sometimes it switches from side to side between attacks — i.e., your first migraine of the month is unilaterally sited on the right side of your head behind your right eye and the second is unilaterally sited on the left side of your head behind the corresponding eye. Intensity of pain is extremely variable from headache to headache, and can last anywhere from a couple hours to a couple days — though there are some people who are afflicted with low-intensity migraines that last for weeks. This is my current personal standard for “obviously being fast-tracked for karmic burn in order to hasten their entry into Nirvana.” The pain is debilitating but frequency of occurrence is also highly variable — some people have multiple migraines a month, some have a migraine every few months, some have migraines once or twice a year — and long periods of “remission” where no migraines occur at all are possible. (My personal longest remission period? Six months.) The clinical description of migraine pain is one of the things I liken to calling the Titanic a big boat: technically correct, but still a massive understatement. The strobe light of pure agony analogy is about as accurate as I can get to an adequate descriptor myself.

Postdrome is the clinical term for the hours/days immediately after the migraine attack, where you can still be feeling some symptoms but in general your ability to function is normalizing again. Some of the physical side-effects tend to linger — soreness, residual nausea, rebound headaches if you’ve taken a lot of meds to interdict the migraine itself, mood swings. Some people I know liken it to feeling hung over. I consider myself lucky to not get the lingering malaise aspects of prodrome, or at least not get them a large percentage of the time. After a migraine, I usually feel good — like you feel better once you’ve thrown up when you’re feeling nauseous — like my endocrine system wants to prove it still loves me by giving me a double-shot of allllllllllll the endorphin, an offer I usually graciously accept.

Like I said further up, there’s quite a bit of debate about the actual root cause of migraine headaches. It’s generally believed that, among other things, they can be triggered by exposure to the chemical constituents present in — guess! — certain foods. You may have noticed that I’m a quasi-vegetarian. (I think the actual persnickety “correct” term is lacto-ovo-piscotarian because I eat milk, eggs, and fish as my major non-vegetable sources of protein and no I don’t give a crap about the horrors of industrial fish farming. I will never give up tilapia. Never.) I made that particular “lifestyle choice” because it simplifies food trigger avoidance rather significantly, because I’m triggered by most of the crap you find in processed food. Sulfites, nitrates, monosodium glutimate, high amounts of just standard sodium. I love salted mango lassi with all my heart, but I don’t drink a gallon-sized cup of it every day and twice on Sundays. When I want Chinese, I cook my own, and only drink alcohol occasionally and in relatively small quantities. Claudio’s Specialty Foods is both my new true love and the bane of my existence because I can get basically all the soft, new cheese that’s safe for me to eat there and have reckless encounters with all the sharp, aged cheese that I should avoid all in one store that is also full of processed meats that are plotting my death. Rin thinks I’m the most desperately deprived person on Earth because I can only eat chocolate if I’m in the mood to take my life into my own hands and have to regulate my caffeine intake pretty exactly, whereas she lives on a diet of theobromine and phenethylamine, canned bacon, and highly caffeinated energy beverages (aka, “liquid migraine in 2 to 16 ounce form”). Sugar and honey are actually better for my brain function than most artificial sweeteners. And those are just my personal triggers. Food and food additives are major triggers across a good chunk of the migraineur population. So are generalized life stress, changes in sleep patterns, physical exertion, hormonal changes, environmental changes.

Most of the major non-pharmacological migraine interventions involve trigger avoidance or mitigation. Eating a diet that avoids or sharply reduces intake of aggravating substances. Moderate exercise taken daily or weekly — back in Cali, I took exercise in the form of swimming and regular biking. I totally need to get another bike. Relaxing through some structured form like yoga or meditation, regular therapeutic massage, or just some low-stress activity like reading (which I do quite a lot) or gardening (black thumb of death, and my grandmother is so, so disappointed by that). Maintaining a regular sleep schedule, which is basically out of the question for me given the realities of my career. Taking rest in a room that’s really dark and really quiet during prodrome. Some people swear by acupuncture and herbal supplements but my results with everything but massage have been only fair to middling. On the other hand, as far as a relaxant goes, pretty much nothing beats forty-five minutes of deep tissue followed by hot stones and a long soak in warm water.

Pharmacological migraine management takes two forms: pain relief and interdiction. Ideally, you’re supposed to take your painkillers as soon as you recognize the symptoms of migraine, which is why it’s a good idea to carry at least a few doses of your med of choice on you at all times. I personally use Imitrex (straight sumatriptan) or Treximet (sumatriptan plus naproxen sodium) for pain relief during the course, plus sound reduction head phones and a sleep mask to help block out light. There are at least a couple OTC pain medications that purport to be specifically for migraine relief and, to give them the credit they deserve, they can help with moderate pain. More severe migraines require more powerful medicines — triptans, which mimic the function of serotonin, ergotomines, specific anti-nausea medications, some opiates, some corticosteroids. If you have frequent, severe migraines over a long period of time, or severe migraines that respond strongly to triggers (such as I do), you’ll likely end up on some sort of long-term interdiction medication, which are usually prescribed for daily intake (to establish maintenance dosage) or (like me) after you’ve been exposed to a known trigger. I take metoprolol in slow-release form for interdiction purposes.

Note: No matter how bad your migraines are, they should not cause your brain to shut down, nor is total brain shut down a side-effect of any medication or combination of medications you could be taking. Yes, I am totally hung up on this.


~ by Dr. Nate Harada on January 29, 2012.

One Response to “Since you asked, Anonymous…”

  1. Yyyyeah, I was wondering how long it was going to take the folk in white coats to start converging on you. At least once technical failure was ruled out.

    Not that I’m saying there wasn’t every chance it would be ruled out.

    What do they want to do, run more scans? What do they think they’re going to find?

    Being a migraineur sounds…complicated. Are you sure it hasn’t maybe raised your ‘weird shit’ bar above the really safe and cautious level?

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