From my early teenage years, I have been suffering from migraine headaches. I can recall it as far back as my second year of secondary school. Now, I know it was related to stress and the things I was going through then. At that time, the headaches were so severe and frequent that I would be in so much pain that I would be admitted to the hospital on some occasions. I remember my parents sleeping outside my hospital ward, and my brothers and cousins following me to the hospital. But not surprisingly, because of the frequency of the headaches, they decided to do further investigations. Still, from the limited tests they did, for one reason or another, they could never pick up that it was not malaria, and I was suffering from migraine headaches.
Throughout the time I was in secondary school, the symptomatology (the study of what a patient complains of in various diseases) of the headaches was such that they would start with an aura (a sensation or feeling before an attack of epilepsy or migraine headaches), which was like light flashes in my eyes and visual distortions – shimmering, jagged, or kaleidoscope patterns drifting across my field of vision. Then I would have localised pounding headaches around my eyes; it usually started around one of my eyes, and then it would spread to both and so on and so forth. The term used to describe it would be 'head-splitting', as if someone were constantly banging my head with a hammer with full force. There was no associated fever or sweating. Although the pain could become so severe that it could make me vomit. A lot of people believed I was playing sick to get pity, which caused some resentment towards me.
All the doctors who saw me from secondary school through my A-levels were diagnosing malaria, which was a common disease, so I was constantly on antimalarial medication. It was so constant and frequent that people thought I was suffering from sickle cell anaemia, and they labelled me as a sickler. I was also very thin in those days, and my bones would stick out; some of my mates then called me 'mosquito' because of my skinny frame. I do not blame the doctors, as in Nigeria, treating any fever or headache with antimalarial medication might help. Still, it can modify the symptoms, especially if the patient is given an antipyretic (a medication that reduces fever) and an analgesic (a medication that relieves pain). But in a lot of the cases, the disease the patients are suffering from is malaria, and because malaria is so endemic, it may mask or modify the actual disease. So, treating them with antimalarial medication will reveal the symptoms of the underlying disease. But with a disease that seems to disappear after treatment, the treatment would be considered effective. My mother was so concerned that she went native. I remember bathing in and being submerged in a hot, steaming traditional native concoction; drinking it; and, on numerous occasions, being under a thick blanket, inhaling the steam to treat the ever-recurring 'malaria'.
Also, I have seen renowned doctors, including our private hospital doctor, at a clinic in Bacita and at other major hospitals. I was seen by various consultants in the general hospital, and still, they would diagnose it as 'malaria'. But none of them had it in their minds to refer me to a teaching hospital or a specialist hospital. But by evening, I would be back to normal. This added to the suspicion that I might be pretending, or that my malaria was different, or that I was suffering from sickle cell disease. I felt that I was spending more time recovering from the side effects of the medication, as I was often given an injection of Novalgin (active ingredient: metamizole sodium – a thick, viscous liquid used for pain) and the itching as a result of the chloroquine injection. This was very painful, as the Novalgin injection was a thick fluid that had to be administered intramuscularly, very slowly, via a wide-bore needle. After receiving the injection, you had to sit down for a while, as walking might be difficult; it kind of made your leg feel numb if the injection was given in your buttock (which it usually was) or your arm go numb if given in your shoulder (I never received it there) and generally weak, as if all your energy had been drained out of you by this single strong injection. Sometimes it would be as if the room or the whole world were turning around you; other times, I would faint after the injection, and it would add to the symptomatology of someone suffering from malaria.
As a doctor, throughout my time in medical school, the emphasis was on listening to the patient and getting a story. Our consultants would be mad if we made a wrong diagnosis because we did not pick up a particular symptom, and they would actually fail you in some cases. In my situation, the headache that I was suffering from produced a unique kind of story. The story was there for all to see, and it was a typical medical textbook case. A preceding aura, a severe throbbing, splitting headache behind the eye, no associated fever, sweating or chills. Then, sudden relief with little or no evidence after less than 12-36 hours. Most of the doctors see themselves as detectives, and they listen to every word you utter to solve the case and come up with a diagnosis. Each disease has a specific story when it occurs, and the type of fever, the headache, the kind of headache, etc., can change the symptomatology and paint a different picture; hence, the doctor will reach a different conclusion and diagnosis.
We would spend hours listening to different stories and debating their differences and similarities. Did the fever come before the headache? When was the fever worse? Did the fever come with chills? What type of headache was it: throbbing or pressure-like? Although the stories could be similar, this will be a differential diagnosis. The child in me would have blamed me for not telling a proper story. Still, the doctor in me would blame the doctors for not extracting the symptoms, not patiently getting a good story, not listening properly, and not asking the right questions. As they say in medical school, properly clerking a patient is an art in itself and develops with experience. The art of clerking in itself will tell you that the diagnosis and the physical examination are there to rule out any other serious condition and focus on what you suspect. As doctors, we are to use the patient's own language, putting the patient's symptoms in their own words. In the patient's presenting symptoms, there are no fancy medical terms or jargon; they are presented from the patient's own perspective. Hence, anyone reading your notes can make up their own mind about what the patient is actually trying to convey, not what the doctor thinks is wrong. Emphasis is placed on clerking, especially in jurisdictions with no investigative infrastructure. However, the symptoms might also be messed up by visits to traditional doctors and backstreet nurses, who would have given them their own "treatment". But we would enquire how they felt before going to see the herbalist and what the story was before they sought any medical intervention. This would make the patients extremely guarded, as before coming to the teaching hospital, they would have been warned not to mention these visits, making it difficult, though not impossible, to get a fuller picture. But there are tricks and ways of getting the patient to tell you the truth; you could ask the same question differently or make the patient feel at ease. Then, further investigations are just to confirm and rule out what you already know or suspect. Now, at the end of it all, if you are still unsure, you will request further investigation and tests. You will review your diagnosis and can refer the patient to a specialist, who, after reading your referral letter, will start afresh with the patient from the very beginning with a fine-tooth comb to ensure that nothing was missed and that the patient was not misdiagnosed.
It was only when I got to the University of Ibadan (UI) in 1985 that it was diagnosed as a migraine headache, and I was given appropriate medicine. The doctor who saw me was a staff doctor at the university. It might be because he was in a university setting and seeing young adults, and migraine headaches are so common in the cohort. Immediately, he knew the story and could relate it to the correct diagnosis. Since that time, I found out that I was not actually a sickle cell patient, and I was more of somebody who had migraine headaches; as long as I took medication whenever I had the aura, the painful headache could be prevented. I would take ergotamine tartrate, and it was a lifesaver, as it stopped any attack of migraine. But I had to be very careful, as it takes time to act, and it did not work once the headache had started. Also, it causes constriction of the blood vessels and could lead to gangrene of the digits (i.e., fingers and toes). Seeing the gangrenous pictures in the medical textbook also burns the image into your head, and you'd rather have the painful headache than lose your fingers and toes. That limited me in using the prevention and made me painfully aware that it is for protection from the headache in the early stages and not for the treatment of the severe, painful headache once it has started. The migraine headaches stopped occurring when I started using carbamazepine for another condition. Still, since I've been taking it daily and it is used in migraine prophylaxis, the attacks have stopped.
Also, I was given glasses, as I had a different type of headache when reading after 2 hours. This was a fuzzy pain in front of my head. It was unfocused, but it felt like a strain. After getting the glasses, I could read much longer; this was also common among young adults. I was always sitting in the front of the class, but did not consider myself myopic (short-sighted). All I knew was that after some time, I developed stress headaches, which were quite different from migraine headaches. This was like a band of pressure across the front of my head, and this stopped when I closed my eyes for a while. Hence, going to UI improved my life tremendously, and I believe going there was one of the best things that ever happened to me. I would always be grateful for the nameless university staff doctor I saw at UI in 1985.
Comments
Post a Comment