St. George, the Maiden, the Dragon and the Ballet of Blame . . . A Migraine Metaphor

It may be a shot of melodrama, a bit of sexism, a hint of narcissism (suggesting that we headache specialists are represented by a saint) yet the allegory is the proper framework for the point I want to make.

Imagine that the Dragon is that terrible disease of migraine, the maiden its victim and St. George the one is trying to tame or even slay the dragon and help the maiden. In the original story, the dragon lived in a lake outside the village of Silene (Libya). Each day the villagers fed the dragon two sheep. If the sheep didn’t satisfy his appetite, then the villagers own children would be selected by lottery to be fed to the beast.

One day the king’s own daughter was selected for the dragon’s meal. The king was deeply distraught and offered his riches if someone would take his daughter’s place. There were no takers and the princess was led to the pond.

St. George, a knight in proverbial shinning armor, happened to be riding by at the time the maiden was being presented to the Dragon. He charged the beast with his sword drawn. He subdued it, and called for the maiden’s girdle, which he threw over the dragon’s neck. He presented the broken monster back to the maiden as her obedient pet.

Migraine is a ferocious dragon. Sixty present of the time it is slayable. Twenty more percent of the time it is tamable. However, the last twenty percent of the time . . . the beast continues to reign despite George’s most noble attempts. In the past few weeks, it seems that there have been more formable dragons than usual. I think part of the reason is that we are seeing more difficult patients each week from a greater distance.

I’ve noticed a pattern over the years that the response to the untamable dragon is the ballet (or waltz may be a better word) between St. George and the maiden as to whom must carry the burden of the blame.

The word we use for migraine that’s resistant to all treatments is “refractory.” Study after study says that despite our best measure, twenty percent of migraines fall into that category. The way in which St. George makes his first step of the “blame waltz” is to suggest that the patient . . . or maiden, is in rebound, or simply crazy (speaking flippantly of serious mental health issues). That is our, the headache specialist’s, way of keeping our chins up and our self-confidence alive. “It is your (the patient’s) fault that you didn’t get better because you took too much ibuprofen (I don’t know of a single study that suggest that anti-inflammatory drugs can cause rebound), or you’re taking too many triptans (a rare cause of rebound) or you are anxious . . . or don’t love your mother.” The blame can go on and on as the music of the Blue Danube plays on.

On the other side of the dance floor the maiden, her husband, her out of state mother or sister. . . who just happens to be a RN . . . start to get angry at George? “You’re an idiot!” They scream on the phone. “Why didn’t you do an MRI? Why didn’t you use treatment X? Everyone on the Internet who tried it got better. I want to take the maiden to a different knight . . . one in the big city. There Dr. House will figure out how to slay the beast!”

But the real truth is, the dragon is formable. Even when we do slay it, and we do most of the time, we have a lot of luck in our favor. To see a dose of sumatriptan bring the beast to its knees is a breath of fresh air . . . if not that, a shot of DHE 45 . . . or maybe a little acupuncture thrown in. It is inevitable that despite the best research, our deepest empathy (and sleepless nights thinking about our patients) and our most grueling labor . . . the beast devours and conquers some of the children

But St. George, the maiden (and the maiden’s family) must remain on the same team. They are colleagues and confidants. We must join arms and continue the fight with a mutual respect. It is the dragon we must hate and blame . . . not one another.