For the past six months I’ve had sporadic tenderness on the top left side of my scalp. My GP said it was a migraine and prescribed Migraleve, which did not help. I can’t touch the area without feeling discomfort; even showering and combing my hair is uncomfortable. I’m very worried and don’t want to be fobbed off by my GP again. I’m 43 and also have an underactive thyroid gland.
Shanaz Bobat, London.
Your description of a recurrent left-sided headache is what has lead your doctor to make the diagnosis of migraine.
However, on the basis of the information given, like you, I am not convinced this is the problem — migraine isn’t associated with scalp tenderness.
There is a more likely possibility; a cause of headache that’s rarer, but that fits your description better: occipital neuralgia. This condition is thought to stem from the irritation or trapping of one of three nerves supplying the head and scalp — the greater occipital nerve, the third occipital nerve and the lesser occipital nerve.
Fact: The pain of occipital neuralgia comes and goes, is of variable intensity, and may be triggered by activities such as hair brushing
This may occur due to muscle tension or injury. The condition is most common among those with neck problems, such as osteoarthritis, which may lead to inflammation which irritates the nerve — it is also more common among those with gout, infection (this causes inflammatory responses throughout the body), or, in rare cases, a tumour pressing on the nerve.
The pain of occipital neuralgia comes and goes, is of variable intensity, and may be triggered by activities such as hair brushing, or by the impact of shower water; exactly the symptoms you describe.
The sensation is usually on one side (although it may sometimes occur on both sides), starting at the point where the top of the neck meets the skull and spreading up towards the top of the head.
There may be tenderness if you press on the affected area, and some patients report tingling as well as pain. You may also find that tapping your fingers over the affected region triggers painful spasms.
The diagnosis can be confirmed using the actual treatment for it — blocking each of the nerves in turn with local anaesthetic and steroid injections. This gives immediate relief that may last for weeks or even permanently, but it must be done by an experienced neurologist or neurosurgeon.
Treatment: The diagnosis can be confirmed using the actual treatment for it — blocking each of the nerves in turn with local anaesthetic and steroid injections
Usually, the condition stops spontaneously weeks or months after it begins. If the procedure is ineffective, the cause of the pain is not occipital neuralgia and a specialist will need to evaluate your symptoms further.
My advice, therefore, is to consult your GP again, explain that the prescribed medication hasn’t helped and describe your symptoms once more.
Mention the tenderness of your scalp, your lack of visual symptoms and nausea (which many people with migraine will experience), and request a referral to a neurologist to consider the diagnosis I have mentioned.
I do not believe your underactive thyroid is related to the symptoms you describe.
My 16-year-old niece has been diagnosed with anorexia. I noticed last year that she was talking about calories a lot and was obsessed with exercising. Then it suddenly became a lot worse.
She is having weekly hospital appointments, but she’s not able to go to school because she is so underweight. My sister is devastated and it’s affecting the whole family: my niece has gone into her shell. Is recovery going to be a long process?
Name and address supplied.
People with anorexia nervosa avoid eating and may obsessively exercise to satisfy their drive to weigh less, even though the weight reduction they’re trying to achieve is under what is healthy.
However, they don’t see it like that, rather believing that they are fat and adopting complex strategies and abnormal behaviours to minimise or avoid eating.
Patients often wear baggy clothes to attempt to conceal how thin they are, and will vigorously deny that there is a health problem. The condition is often linked to poor self-esteem, and patients see thinness as a way to improve their worth.
People with anorexia avoid eating and obsessively exercise to satisfy their drive to weigh less
But they are, in effect, starving themselves. As a result, malnutrition is common, so periods normally stop, bones may be weakened and heart rhythm irregularities can occur.
Normal brain function is also strongly affected, leading to depression and anxiety. Problems with sleep, memory and thinking clearly are typical, too — as is the social isolation or withdrawal you are seeing in your niece.
The cause of this condition, which affects about 0.3 per cent of adolescents and more than 2 per cent of adults, is not known, though there is some evidence of a genetic basis.
As the condition develops, the patient experiences changes in brain function, some of which can be identified in scans — though currently it’s unclear whether these changes are causal or an effect of the malnutrition.
Your niece will be under the care of a specialised unit, typically with a consultant psychiatrist specialising in eating disorders as team leader, assisted by specialist nurses, dietitians, clinical psychologists and psychotherapists.
It is unlikely to be a speedy recovery. Your niece may well be undergoing treatment for a year or two — or longer. UK research suggests that about 50 per cent of patients gain weight and have a good outcome, but others may continue to be withdrawn and resistant to treatment.
However, many of the studies that reveal these rather gloomy figures have been based in specialist hospital units, and it may be that outcomes are more favourable in those not so severely affected that they need inpatient hospital treatment.
Those who are able to remain at home with their families during the course of their treatment have better outlooks. With the right help, there is no reason your niece should not go on to have a healthy, happy life, free from anorexia.
I very much hope this proves to be the case.
IN MY VIEW…BEWARE THE PHONE CONSULATION
Recently I appeared in court as an expert witness following the death of a child from appendicitis. Over a number of days, the parents had consulted three GPs about the symptoms by telephone — there being no appointments available — and each time they were told ‘it is just a winter vomiting virus, there is a lot of it around’.
Not one doctor actually examined the child, despite their continuing to be so unwell.
This week, I heard that an acquaintance went to our local surgery with abdominal pain only to be met by someone who called themselves a ‘practitioner’ — not a nurse or doctor — who asked about the history of the symptoms but appeared to be reading questions from a typed list. No diagnosis was made and the patient left entirely unconvinced.
Neither story fills me with confidence. Practitioners are being brought in to shoulder much of the routine work of GPs, but they can never take the place of a doctor.
They’re like the police community support officers who were brought on to our streets to create the perception that we were being better protected; while they do a wonderful job, they’re not fully trained police officers.
Similarly, the use of practitioners leads to second-class medical care.
But clearly the current system needs to change — children should not be dying because they can’t get to see a GP.
My proposal is that GPs are no longer subcontracted, like small businesses, but paid a salary and housed in teams at local hospitals, with each GP given a stated patient list to ensure continuity of care.
Access for patients would inevitably improve, as would co-ordination with consultant care, and there would be better communication. There would be direct access to other services such as lab tests, scans, physiotherapy and other paramedical treatments, with one set of medical notes and improved out-of-hours care with properly structured covering arrangements.
To solve the crisis we face we need this sort of root-and-branch reform, rather than trying to heal the gaps in the current system with yet another sticking plaster.