Headache

Asra came to me with a headache. She was a well-built, middle-aged woman with close cropped hair graying at the temples. Her eyes engaged my attention. They were brown, deep-set with dark circles. She had a pinched expression on her face as if her temporal muscles were in eternal spasm.

I thought I was well equipped to handle any headache. I knew about temporal arteritis and regarded myself as an expert in peering through undilated pupils to check for papilledema. I was adept at recognizing the red flags of projectile vomiting, morning headache, and neck stiffness. I had triptans and tricyclics for migraines. I had trained well during my neurology rotations. My armamentarium seemed adequate.

Asra came in with our interpreter. She had been having headaches for 10 years. She told me of magical potions that she had tried for headaches while wandering in central Asia. She shook as she recounted intravenous treatments of unknown medications in faraway Moscow. Instead of delving into the tales of the past, especially because Asra could recount no real medical details, I chose to focus on symptoms and signs of her current “attack.” Her …