A young woman comes to my clinic with the complaint of having had “migraine” for four years. She has seen three doctors and finished a small pharmacy of painkillers, and nobody ever questioned the label.
By the time she sits across from me, she has stopped reading because reading makes the pain swell at the back of her skull, and twice last month she fainted while waiting for an auto.
I ask her one thing none of the painkillers asked: What does your head do when you stand up? It gets worse, she says. Far worse. Lying flat is the only thing that helps.
I see a version of her every few weeks, and that single answer is often the line between a headache and an emergency.
We picture headache as one thing that varies only in how much it hurts. In fact, the head is a pressure system, and pressure can fail in either direction. When the fluid around the brain runs too high, or leaks away and runs too low, the brain protests in the only language it has: pain.
The cruelty is that this pain copies migraine almost perfectly. The one clue it cannot hide is posture. Migraine rarely cares whether you sit, stand or lie down. These conditions care enormously.
Cluster headache, the savage pain that has been called the suicide headache, is also mistaken for migraine or sinus trouble for years, yet the mimics that truly kill are far quieter.
Take Idiopathic Intracranial Hypertension, where the pressure climbs for reasons still poorly understood. It tends to strike young women, more so as obesity becomes common, and it shows up as a headache that is worse on waking or on lying down, often with a whooshing pulse in one ear and brief greyouts when the person stands. Those greyouts are a warning.
The raised pressure pushes on the optic nerves, and if nobody looks, it can slowly take the sight it was warning about. A doctor can see that danger in under a minute by looking into the back of the eye. Most patients are never offered the look.
Now reverse the pressure. In Spontaneous Intracranial Hypotension, spinal fluid leaks out through a tiny tear or fistula, the brain loses its cushion and sags inside the skull. The signature is exactly what my patient described: fine when flat, unbearable when upright. Left unnamed, it can tear veins and clot the surface of the brain.
In some people, the sagging frontal lobes produce changes in behaviour and memory that look identical to dementia. A family is told that someone in their forties has an untreatable degenerative disease.
Now and then, the real answer is a leak that can be sealed with a patch of the patient’s own blood, after which the dementia or coma lifts. A treatable illness in the disguise of an incurable one.
Then there is the racing heart. In Postural Orthostatic Tachycardia Syndrome (POTS), the autonomic nervous system misfires on standing, the pulse shoots up, and the person feels faint, drained and headachy, with a mental fog they struggle to put into words.
It overlaps with migraine, and with the loose-jointed connective tissue that also makes spinal leaks more likely, so one patient may carry several of these labels at once. Almost all of them, at some stage, are told it is anxiety.
That word is where the harm gathers. These illnesses fall mostly on young women, they are invisible on a hurried examination, and they steal something we almost never measure: cognition.
The brain fog of POTS, the fading memory of a sagging brain, the blunted concentration of high pressure. People lose jobs and degrees and get written off as fragile, while a fixable problem goes unnamed for years.
This is where India should worry. Community studies find that roughly two in three adults had a headache in the past year, and around one in four adults lives with migraine, women most of all, yet fewer than a quarter had sought any medical care for it.
We have a tiny number of dedicated headache specialists for 1.4 billion people, and almost none of the patient advocacy that Britain and the US built decades ago. There, charities fund research, teach doctors to catch the dangerous mimics, and give patients somewhere to turn. Here, a person is mostly left to ration paracetamol and hope.
Headache Awareness Month is a good time to say the unglamorous thing. Most headaches are harmless. A few are not, and they hide in plain sight.
The fix is not exotic. It is asking what the pain does when the body changes position, looking into the back of the eye, and building the advocacy that turns a private misery into something to be taken seriously.
The writer is director of Department of Headache & Facial Pain, Narayana Health, and founder-chairman of World Headache Society