The Migraine That Wasn't

The medical literature on gender bias in pain management is unambiguous. A 2001 study in the Journal of Law, Medicine & Ethics titled "The Girl Who Cried Pain" documented that women are significantly more likely than men to have their pain symptoms attributed to psychological causes rather than investigated for organic pathology. A 2018 analysis in Academic Emergency Medicine found that women presenting to emergency departments with acute abdominal pain waited an average of sixteen minutes longer than men for pain medication — and were less likely to receive opioid analgesics when they did receive treatment. This is not subtle. It is well-documented, well-replicated, and almost never addressed.

I thought I was immune to this bias. I am a female neurologist. I specialize in headache medicine. I treat women with chronic pain every day. I could not possibly be one of those physicians who dismissed women's symptoms. Until I was.

Claire came to my clinic with a ten-year history of chronic headaches. She had seen five neurologists before me. She had tried beta-blockers, calcium channel blockers, tricyclic antidepressants, anticonvulsants, Botox injections, and the new CGRP monoclonal antibodies. Nothing had worked. Her previous physicians had diagnosed her with chronic migraine, medication overuse headache, and — when the treatments failed — somatization disorder. The chart notes from her last neurologist read: "Patient reports persistent headaches despite maximal medical therapy. Likely psychogenic component. Recommend cognitive behavioral therapy."

I reviewed her chart before the appointment and — I confess — I prepared to have the same conversation. Chronic headache patients who have failed every treatment are common in my practice, and the honest truth is that some of them do have a significant psychological overlay. I was ready to recommend therapy, stress reduction, and acceptance.

Then Claire described her headache. It was not a standard migraine — it was worse when she lay down. Much worse. She slept sitting up in a recliner. She had stopped exercising because bending forward produced excruciating pain. When she coughed or sneezed, the pain was so severe she nearly lost consciousness. These are not migraine features. These are features of increased intracranial pressure.

I ordered an MRI venogram. It showed bilateral transverse sinus stenosis — narrowing of the major veins that drain blood from the brain. Her cerebrospinal fluid pressure, measured by lumbar puncture, was 35 cm H2O — more than twice the normal upper limit of 15. The diagnosis was idiopathic intracranial hypertension, a condition that causes exactly the symptoms Claire had been reporting for ten years and that five neurologists, including — almost — me, had attributed to stress.

Claire underwent venous sinus stenting, a minimally invasive procedure that opens the narrowed veins. Within forty-eight hours, her headache was gone. Ten years of pain, dismissed by five neurologists, cured by a diagnosis that a careful history would have suggested at the first appointment — if anyone had been listening.

I was not the first neurologist Claire saw. I was the sixth. And I almost made the same mistake as the previous five. The lesson I carry from Claire's case is that bias is not a personal failing — it is a cognitive pattern, and it operates below the level of conscious awareness. The only defense against it is vigilance. And sometimes, even vigilance is not enough.