When a migraine is more than a headache: The clinical negligence aspects of a migraine misdiagnosis

By Alison Johnson, clinical negligence partner, Penningtons Manches Cooper LLP

Migraines are complex neurological conditions that can cause debilitating symptoms. The cause of migraines isn’t fully understood, but there are several key factors known to contribute.

The first factor is genetics. Migraines often run in families. If one or both parents suffer migraines, there’s a higher chance their children will too.

Neurological factors are also relevant as during a migraine, certain nerves in the brain are activated, which send pain signals and release inflammatory substances around the blood vessels in the head.

This inflammation is believed to contribute to the pain.

Hormonal changes can play a part and fluctuations in oestrogen, especially in women, can trigger migraines, explaining why migraines are more common in women and often linked to menstrual cycles, pregnancy, or menopause.

Environmental and lifestyle triggers can include stress, bright or flickering lights, strong smells, changes in sleep patterns, weather changes, skipping meals, certain goods, alcohol, excessive caffeine, or caffeine withdrawal.

Finally, some medications, such as oral contraceptives or vasodilators, can trigger or worsen migraines for some individuals.

Migraines can sometimes be a symptom of or associated with more serious underlying health conditions.

While migraines themselves are not usually caused by these conditions, their presence may signal a need for further medical evaluation.

Those serious health conditions include stroke, heart disease, epilepsy, brain tumours, sleep disorders, hearing loss, mental health conditions such as depression, anxiety and bipolar disorder, and pregnancy complications such as pre-eclampsia.

If migraines are new, changing in pattern, or accompanied by unusual symptoms (including confusion, weakness, or vision loss), it is important to seek medical attention to rule out these more serious conditions.

When a neurologist investigates migraines, the process typically involves a combination of clinical evaluation, diagnostic testing, and exclusion of other conditions.

A neurologist should take a detailed history, asking about frequency, duration, and intensity of headaches, whether there is a family history of migraines, what triggers there may be and the impact on the individual’s daily life.

A physical and neurological examination will help rule out other neurological conditions in a process of elimination. Investigations undertaken are likely to include reflex tests, muscle strength and coordination checks, sensory function assessments and eye movement and vision tests.

Depending on the findings of those, the individual may then require imaging tests used to rule out serious underlying conditions.

An MRI (Magnetic Resonance Imaging) is undertaken to detect tumours, strokes, or structural brain abnormalities. A CT scan (Computed Tomography) is often used in emergency settings to check for bleeding or trauma.

An MRA (magnetic resonance angiography) or MRV (magnetic resonance venography) is used to examine blood vessels in the brain if vascular issues are suspected.

An EEG (Electroencephalogram) is used less often but may be ordered if seizures are suspected alongside migraines.

The cause of migraines is often reached by excluding other causes of headache, such as brain tumours, infections (e.g. meningitis), aneurysms, intracranial hypertension (raised blood pressure in the skull) and sinus disease.

Having delayed investigations into migraines and a delayed diagnosis can result in a serious situation, as some conditions that mimic migraines are much more dangerous and require urgent treatment.

Misdiagnosis can delay proper care of brain tumours as persistent headaches misattributed to migraines may be due to tumours, which can grow and cause neurological damage if untreated.

Infections such as meningitis can present with headache and fever and if mistaken for a migraine, they can progress rapidly and become life-threatening.

Some migraines, especially with aura, mimic stroke symptoms, but the reverse is also true, in that strokes can be misdiagnosed as migraines, delaying critical intervention.

A misdiagnosis can lead to inappropriate or ineffective treatment.

For example, treating a non-migraine condition (epilepsy, Meniere’s disease, or post-concussion syndrome) with migraine medications can be ineffective or even harmful.

Patients may then be exposed to unnecessary medications, side effects, or procedures without addressing the root cause.

Misdiagnosed patients may then endure years of ineffective treatment, leading to chronic pain, disability, and emotional distress.

Conditions such as brain tumours or autoimmune diseases may worsen over time if not diagnosed and treated promptly.

Furthermore, there can be psychological harm caused when patients are told that symptoms are “just migraines” when they’re not, leading to feelings of frustration, anxiety, or being dismissed.

Misdiagnosis may also mask coexisting mental health conditions such as anxiety or depression, which require different treatment

If you or someone you know has migraines that are changing in pattern, unusually severe, or accompanied by new symptoms (vision loss, weakness, or confusion), it’s important to seek a second opinion or request further testing.

Failure to investigate the cause of migraines could potentially be considered negligent, depending on the specific circumstances.

There may be clinical negligence when a patient presents with red flag symptoms (e.g., sudden onset, neurological deficits, vision changes) and no further investigation is undertaken.

The migraines are new, worsening, or unresponsive to treatment and no imaging or referral is made.

A serious underlying condition (e.g. brain tumour, stroke) is missed due to lack of appropriate testing and the subsequent delay in treatment causes what should have been avoidable further injury.

Alison Johnson, Partner in the clinical negligence team at Penningtons Manches Cooper, has expertise in investigating neurological claims, in which lack of investigations into migraines often features.

Alison recently investigated and settled a claim for a young woman who had suffered debilitating migraines for an extended period of time, but in fact had an intracranial aneurysm.

The claim arose from a failure to follow up the aneurysm, which required ongoing monitoring and at the appropriate time, treatment by way of endovascular surgery. She did not receive that monitoring, the aneurysm grew and ruptured, causing her to suffer a subarachnoid haemorrhage (a significant brain bleed).

She required an emergency hospital admission, a lengthy rehabilitation from her brain haemorrhage both in hospital and at home, had ongoing physical effects of the haemorrhage, including right-sided weakness, as well as ongoing cognitive and psychiatric injuries.

About the Author

Alison Johnson is a leading clinical negligence solicitor based in the southeast of England but representing clients nationwide. She has worked with individuals and families impacted by medical negligence for over 20 years.

She is a member of Action against Medical Accidents’ (AvMA) Clinical Negligence Panel and listed as a next generation partner in Chambers UK and Legal 500, gaining acknowledgement of her hugely effective combination of intelligence, empathy and sound judgement, ability to put clients at ease and for being a very good and effective litigator.

Alison is available for an initial chat about a new or existing clinical negligence claim and can be reached at: alison.johnson@penningtonslaw.com