Introduction
Headaches are not an uncommon human experience and present among the most frequent complaints in clinical practice. Headaches have been described since antiquity, and there are over 200 varieties currently described, often making the diagnosis and treatment a challenging task. The International Headache Society listed over 200 varieties of headaches in 2018, with diagnosis based on history, presenting symptoms, without any imaging or laboratory test to differentiate between the different types of headaches. This article discusses the case of a 24-year old female that presented with severe right-sided headache (10/10), vomited three times in the last three hours, and states her eyes hurt. It was the sixth time she had had the headache in two months, impairs her ability to work. This article discusses the pathophysiologic process that would account for her symptoms, the racial/ethnic variables, and how they interact to impair the patient’s functioning
Pathophysiology
The patient’s symptoms are more consistent with migraine headaches, a neurological disorder characterized by headache lasting for more than 72hrs. The distinguishing features are unilateral throbbing pain that can vary in severity from mild to severe. It is accompanied by at least one of nausea/vomiting, photophobia, or phonophobia. The patient headache is right-sided, lasts 48 to 72hours, accompanied by vomiting and photophobia.
The pathophysiology basis is complex and largely remains unknown, with no identifiable pathology. However, associated brain metabolism and blood flow changes accompany migraines, which support neurologic, vascular, hormonal, and neurotransmitter hypothesis components of migraine pathophysiology. Migraine aura is associated with spontaneous, self-propagating wave glia that begins at the occipital region, spreading across the cortex, referred to as cortical spreading depression (CSD). CSD causes the release of neurotransmitters, which activate the trigeminal nerve. Consequently, there is stimulation and vasodilation of dural blood vessels, central sensitization of pain receptors, inflammation and the activation of the brainstem and forebrain areas that modulate pain. The vasodilation cannot account for the pain, but calcitonin gene-related peptide (CGRP) released by the trigeminal nerve can, as CGRP antagonists stop migraine headache. Also, there are changes in the neurotransmitters, glutamate (increase) and serotonin (decrease), with consequent use of serotonin receptor agonist (Triptans) to treat migraines (Huether & McCance 2016, p 1210)
Racial/ethnic variables and impact on life
According to Charleston & Burke (2018), compared to non-Hispanic whites, African Americans have more frequent, more severe migraines. Migraines are also more likely to become chronic and more associated with depression and reduced quality of life. African Americans are also under-diagnosed for headaches, under-treated, and more likely to stop medication prematurely. According to Hoffman (2016), African Americans are generally undertreated for pain compared to Whites, which is associated with bias and false belief about biological differences even by medical practitioners leading to less accurate pain management recommendation. African Americans are less likely to receive analgesics in emergency rooms, and the trends extend to children, despite having similar self-reports of pain to whites. However, Whites are more likely to receive opioids and over-prescription. Under medication in blacks and over medication in whites is a documented phenomenon that is race-associated.
In conclusion, the client’s symptoms are more consistent with migraine. The pathophysiological basis remains largely unknown. However, there associated brain metabolism and blood flow changes that accompany the migraine, which support neurologic, vascular, hormonal, and neurotransmitter components of migraine pathophysiology. Racial bias and false belief about biological differences in pain management disproportionately affects African Americans, leading to under mediation in blacks and over-prescription in whites