The Correct Diagnosis – Ten Years Later

Wanda has been my patient for over ten years. She has these spells that nobody could figure out. She had seen a couple of the doctors in our clinic and at least two neurologists. She was even admitted to a hospital a hundred miles away for EEGs and videotaping of her spells.

When I first met Wanda, she described spells of confusion accompanied by a slight headache, severe anxiety, nausea made worse by the smell of food and abdominal cramps. Her husband wouldn’t be able to talk with her, and she would have trouble remembering the entire episode after it was over.  The episodes often occurred during her period. The neurologists suspected seizures, but the video-EEG showed rather bizarre moaning and groaning with a normal EEG, so the conclusion was that she had pseudoseizures. This is a condition that basically falls under anxiety disorders.

None of the anxiety medicines did anything for Wanda and she insisted she wasn’t anxious. She is an accomplished businesswoman who travels, gives presentations and generally seems to be at ease with everything she does.

Wanda is not a complainer, so years went by without her bringing up her spells. She would come in for routine things and occasional minor illnesses, but she never spoke much about the spells.

Then one busy Friday she turned up as my 4:30 patient with the purpose of the visit stated as “spells”. Looking at my schedule that morning I had remembered how none of her doctors had been able to help her. I was tired and running late because of a couple of late-day emergencies, so it was about fifteen minutes of five when I knocked and entered her exam room. I was not in high hopes of solving her problem before 5 pm.

When you get stuck in a diagnostic dilemma you have two ways of approaching the problem. You can dig deeper and meticulously go over all the tests that have been done so far, looking for anything that could have been missed. You can also do the opposite, step back, clear your mind and listen to the patient’s story all over again. It is a little bit like those pictures in psychology class; the more you stare at them, the less likely you are to see the hidden image. Sometimes if you squint, you can see it right away.

Given the time available and also the amount of time that had passed since Wanda had anything done to figure out these spells, I chose the latter course. Instead of acting frustrated that I had an unsolvable problem at 4:45 on a Friday afternoon, I sat back, took a deep breath and asked Wanda to start from the beginning.

As I listened, I started to think that all of these symptoms sounded a little like migraines, except that the headaches were mild and sometimes absent. Some people have neurological symptoms with migraines. The nausea and abdominal pain, which she now described as bloating, sometimes followed by diarrhea, can be seen with migraines. There is a rare form of migraines called abdominal migraines or Cyclic Vomiting Syndrome, usually found in children. Her spells were getting a little less severe as she was approaching menopause, but they were interfering with her work, especially as she had to travel more in recent years. Migraines are more likely to occur when people aren’t following their normal routines – missed meals, lack of sleep and jet lag are all migraine triggers. There is also the phenomenon of “weekend migraines”.

I told Wanda that her story made me think of migraines. She lit up. It made sense to her and she was pleased that I was willing to go in a different direction. I gave her samples of Imitrex to be taken with attacks and a prescription for a common blood pressure medication that is often used for migraine prophylaxis. 

Within a month Wanda was almost free of the severe attacks, and she had stopped a couple of spells by taking the Imitrex. With her permission I sent copies of her records to a migraine specialist in Boston for his review. He confided in me that he had always been sceptical of abdominal migraines in adults, but agreed that I seemed to be on the right track. We are now adjusting her preventive medication because of side effects.

It took ten years to make the correct diagnosis – or, should I say, ten years and fifteen minutes. I can certainly not pat myself on the back for getting it right without feeling very humble about how we all missed what was going on for so long. Sometimes when you’re tired your mind can work more intuitively, and I think that is what happened here.