Discussion

Jefferson

Thomas Jefferson, third president, had severe occasional headaches, with the first around the age of 20 usually triggered by stress, lasting days to weeks[5] that Cohen and Rolak found consistent with probable migraine.[6] An incomplete description of Jefferson's headaches is available, but it is known that his headaches could be severe, were aggravated by exercise, and were accompanied by light sensitivity.

Documented episodes of prolonged headache associated with stress include the following: the first after a failed courtship; the second after the death of his mother and just before he was assigned to author the first draft of the Declaration of Independence; the third when he was recalled from Paris and while coping with other personal issues; the fourth while secretary of state and involved in the dispute over the location of the nation's new national capital; and the fifth while he was clashing personally and politically with Alexander Hamilton. Jefferson called his attacks "inveterate headaches."[7]

Jefferson's descriptions of his own headaches in letters and account books are incomplete but give us some insight into his suffering and impairment.[8] On March 20, 1764, "I will endeavor to answer it as circumstantially as the hour of the night, and a violent head ach, with which I have been afflicted these two days … My headaches, my candle is just going out …."[9] On May 27, 1790, "A periodical headache has put it out of my power for near a month to attend to any business…."[10] On June 23, 1791, "I am in hopes the relaxation it gave me from business, has freed me from the almost constant headache with which I had been persecuted thro the whole winter and spring."[9] In a letter dated March 20, 1807, while he was president, "Indeed, I have but a little moment in the morning in which I can either read, write, or think; being obliged to be shut up in a dark room from early in the forenoon till night, with a periodical headach."[11] In 1819, at the age of 75, he wrote, "A periodical headache has afflicted me occasionally, once, perhaps, in six or eight years, for two or three weeks at a time, which seems now to have left me…."[12]

Episodic Daily Migraine

For migraineurs who experience only (or primarily) long duration headaches, the author has coined the term "episodic daily migraine."[13] This migraine variant may be expressed by otherwise typical migrainous attacks that last for days, weeks, or even months … separated by headache-free intervals. Such cases previously have been reported by Medina and Diamond as "cyclical migraine."[14] Larger case series would be helpful to better define the spectrum of this presentation and the ranges of duration. Robbins et al have reported 7.5% of patients with new daily persisting headache with a relapsing-remitting type and migraine features.[15] Do these patients have episodic daily migraine? How might one distinguish the two?

Adams

The author can find one reference that John Adams, second president, had migraines also while in Paris in the late 1770s: "With only his Puritan conscience for company in his hotel room, he developed severe migraines…."[16]

Lincoln

Although the author can find few details, Abraham Lincoln, the 16th president, suffered from migraines. While president and weighing recommendations from his cabinet on whether to reinforce Fort Sumter, "The strain under which Lincoln labored in arriving at this decision was immense. All the troubles and anxieties of his life … did not equal those he felt in these tense days. The pressure was so great that Mary Lincoln [his wife] reported that he 'kneeled over' and had to be put to bed with one of his rare migraine headaches."[17,18] Lincoln also suffered from recurring depression from young adulthood.[17]

Grant

Ulysses S. Grant, 18th president, had a history of recurrent migraines from youth that he complained were provoked or intensified by music.[19] Some headaches were treated with chloroform.[20] He described one of his attacks that had occurred on April 8, 1865 when he was 42 and in the final days the Civil War: "On the 8th I had followed the Army of the Potomac in rear of Lee. I was suffering very severely with a sick headache, and stopped at a farm house on the road some distance to the rear of the main body of the army. I spent the night in bathing my feet in hot water and mustard, and putting mustard plasters on my wrists and the back part of my neck, hoping to be cured by morning."[21] The headache was still present the next morning when a messenger arrived with a letter from General Robert E. Lee (also a migraineur[22]) who at last was requesting "an interview in accordance with the offer [the South laying down their Arms] contained in your letter." As Grant recorded in his journal, "When the officer reached me, I was still suffering from the sick headache; but the instant I saw the contents of the note I was cured."[21]

Wilson

Over a span of 8 of his 50 adult years, Woodrow Wilson, 28th president, suffered at least 14 periods in which "nervousness, dyspepsia, and headaches became so severe as to interfere seriously with his work." Shortly after arriving at Johns Hopkins to start his doctorate in political science in 1883, he wrote, "I over-taxed my eyes yesterday and am today suffered with a dull ache through my head and with throbbing orbs that refuse all use."[23] In 1886, just after completing his doctorate, he corresponded, "I have a rattling headache…."[24] While president of Princeton, he had pounding headaches. Shortly after becoming president in 1913, he started playing golf every day but Sunday prescribed by his physician (and close friend, Dr. Grayson, who was usually his partner) "as a necessary form of exercise for Wilson to battle the anguish of stomach cramps and migraines headaches related to a heart condition that was aggravated by stress."[25] He played at least 1200 rounds as president, perhaps as many as 1600, with an average score of 115.

While on a speaking tour as president prior to his stroke in 1919, he was reported to have daily violent headaches,[26] which were so bad that he could "hardly see."[27] There is no sufficient information available to know whether these headaches might have been migraines or unrelated and perhaps caused by uncontrolled hypertension. He had a history of hypertension, small strokes in 1896 and 1906, and chronic elevation of his blood pressure while president.[28]

Truman and Undiagnosed Migraine

About 50% of migraineurs currently (perhaps a larger percentage in the past) have undiagnosed migraines, which may also have been the case of the next presidents we consider. Might Harry S. Truman, 33rd president, have had migraines? "Upon becoming presiding judge of the county court, Harry began suffering sinus headaches. [Most people with self-diagnosed 'sinus headaches'[29] and many diagnosed by non-neurologist physicians have migraines. Also see Kennedy's visit to an ear, nose, and throat physician below.] Relief came when he packed his bags and went on another Old Trails Road Association trip…." at a remote lakeside cottage. In a letter to Bess in 1927, he wrote, "You don't know how great a relief it is to be loose from that [court] responsibility. I'm not going to think of anyone but my baby [Margaret] and come home without a headache."[30] He later wrote, "I am having a fine time and no expense and I haven't had a headache since I arrived." He is documented as having headaches again as senator during a stressful period when Roosevelt was trying to pack the Supreme Court.[31] (If you have further interest, there may be more information about his headaches available in his Army medical records 1917–1955,[32,33] available at the Harry S. Truman Library and Museum in Independence, Missouri.)

Eisenhower and Possible Migraine

The author found one reference concerning Dwight D. Eisenhower, 34th president, and headache as follows: "He suffered, too, [early 1930s] from a succession of ailments that were almost certainly brought on by stress-mysterious pains in the back and stomach, diarrhea, excruciating headaches. Physical examinations showed nothing seriously wrong…."[34] Migraines?

Kennedy

Several sources quote John F. Kennedy, 35th president, as having made a ribald comment about his migraines.[35] Although this may have been a joke, another source states, "President Kennedy didn't like riding in open motorcades because the bright sunlight triggered his migraines."[36]

In a journalist's review of his medical records, the only mention of headaches was in 1952 when he saw an ENT physician for headaches when he was running for senator.[37] In this journalist's book, he only states, "After the diagnosis of his Addison's disease in September 1947, he continued to struggle with medical concerns. Over the next six years, headaches … plagued him."[38] There might be more information about his headaches in these medical records. (The medical records are those of White House physician, Dr. Janet Travell [myofascial pain pioneer[39]], from 1955 to 1963, who gave him procaine injections in his back. They are available for review by physicians by request at the John F. Kennedy Presidential Library and Museum in Boston; Tom Putnam, administrator, personal communication, July 29, 2011).

If JFK had migraine, perhaps, one migraineur admires another. At a dinner honoring 49 Nobel Laureates on April 29, 1962, Kennedy said, "I think this is the most extraordinary collection of talent, of human knowledge, that has ever been gathered together at the White House, with the possible exception of when Thomas Jefferson dined alone."[40]

More Recent Presidents

I can find no evidence that more recent presidents have had migraines. For example, one source cites Richard M. Nixon, 37th president, as stating, "He also told the physician [White House physician Dr. Tkach] that he had never had a headache. He seemed to think headaches were imaginary – excuses for weak men…."[41] Perhaps they were individuals cut from the same cloth as my brilliant and inspiring (but demanding) mentor and departmental chairman, Stanley H. Appel, MD. I asked him if he ever had migraines, and he replied, "I don't have migraines, I give migraines." It is also possible that a past or future president may have a diagnosis of migraine and not wish to reveal the diagnosis because of concern that the public may misinterpret the significance or interpret the headache as a sign of weakness.

Spouses

It is well-documented that Abigail Adams, wife of John, and mother of sixth president, John Quincy Adams, was a migraineur, as "all her adult life she faced episodic bouts with migraine headaches."[42] Mary Lincoln similarly was a migraineur from early adulthood[43] with a history of depression and possibly bipolar disorder.[18] There is even speculation that she may have been addicted to opiates she took for her migraines.[44] At other periods and while living in the White House, Mamie Eisenhower also may have experienced attacks of migraine. There are references to her having "suffered from violent headaches,"[45] having "prolonged headaches,"[46] and "It was was cool and dark in the bedroom where Mrs. Eisenhower lay, almost insense with pain from a stabbing headache."[47] One biography reports that Jacqueline Kennedy had migraines.[48] Another author reports that Dr. Jacobson (nicknamed "Dr. Feelgood" by his patients) treated Mrs. Kennedy in 1961 for postpartum migraines and depression.[49]

The wife of 2008 Republican presidential nominee U.S. Senator John McCain, Cindy McCain, has bravely come publicly forward to divulge her history of chronic migraine with aura and has become a migraine advocate.[50] She has described how exposure to bright lights was a migraine trigger that caused her to frequently wear sunglasses while her husband was running for president.[51]

Epidemiology, Burden, and Comorbidity of Migraine.— The one year prevalence of migraine in the United States is about 18% for women and 6% for men. About 35 million Americans annually have attacks and approximately 6 million have chronic migraine.[52]

Migraine can be a debilitating disorder even with the best management. For example, up to 40% of all attacks and 25% of all patients do not respond to any of the triptans.[53] About 50% of patients respond to a given first line preventive agent for episodic migraine and about 40% respond for chronic migraine with about 20% of patients not able to tolerate each preventive medication.

Migraines frequently cause disability.[54] Most migraineurs report at least occasionally experiencing severe impairment or the need for bed rest during migraine attacks with only 7.2% reporting no history of attack-related impairment. In one investigation, over a 3-month period, about 35.1% of the migraineurs studied had at least 1 day of restricted activity because of headache, with 25% missing at least one day of work or school.[55] In a survey of a large sample of migraineurs, the mean lost productive time per week was 1.8 hours with 77% of that time explained by reduced performance or presenteeism.[56] Canadian investigators reported that 90% of people with migraine reported postponing their household work because of headaches, 30% had canceled family and social activities during their last migraine attack, and two-thirds feared letting others down because of their headaches.[57] Migraine costs American employers $13 billion per year.[58]

Migraine is also comorbid with many conditions including depression and bipolar disorder[59] (witness Abraham and Mary Lincoln).

Most Migraineurs Function Well (But Consider "Presidential Triggers") Most migraineurs manage well in their lives the vast majority of the time. Candidates for presidents and presidents usually are at an age when the prevalence and clinical activity of migraine are decreasing. In addition, presidential candidates may "self-select," such that those with physical disorders likely to be aggravated by the rigors of public life choose to avoid seeking high office or are unable to get elected. A candidate or president are constantly exposed to a variety of common migraine triggers that are reported by the following percentages of migraineurs: stress, 89%; not eating, 57%; weather, 53%; physical exhaustion or traveling, 53%;[60] sleep disturbance, 50%; perfume or odor, 44%; and lights (such as camera and spotlights), 38%.[61] The physical and emotional stress is obviously extraordinary and the travel can be grueling even if you have your own plane, don't have to go through security or customs, don't have to check in and out of hotel rooms, call for cabs, or even pack your own bags.

The 25th Amendment

Although Section 3 of the 25th Amendment of the U.S. Constitution (passed by Congress in 1965 and ratified in 1967) provides the means for a disabled president voluntarily to transfer the powers of his office to the vice president (to serve as acting president), and Section 4 permits the vice president and a majority of the president's cabinet to transfer powers to the vice president if they deem the president disabled and unable to exercise the powers of government, would either ever be invoked with an ill migraineur president? Although President Reagan was disabled for a considerable period after he was shot, neither section was invoked. President Bush was the first president to formally invoke the third section of the 25th amendment for about 1 hour on June 28, 2002 while undergoing a colonoscopy with conscious sedation.[62] A president can make arrangements with their vice president for use in advance that could include temporary disability because of migraine attacks.

Disabling Migraine Types

Consider just a few of the various scenarios we encounter in everyday headache medicine: chronic migraine which does not respond to preventive and symptomatic medications; migraine status with intractable nausea and vomiting; migraine with diarrhea; basilar type migraine; and migraine with a dysphasic aura (which accounts for about 20% of all auras). The reader may recall the frenzy of media attention involving the television reporter, Serene Branson, an established migraineur with no prior history of aura, who became dysphasic on live television at the 2011 Grammy's. She was perceived by many of the public as having suffered a stroke (reference includes a recounting and video of the event).[63] It is easy enough to imagine the attention and concern this episode would have triggered had it involved a sitting president. What if during a national emergency the president suffered a stress-induced migraine with aura and became dysphasic?[64]

Up to the Voters but Physicians Can Inform

It is up to the voters to decide whether a candidate is qualified in all aspects to fulfill the duties and responsibilities of president. The public should expect candidates for the presidency to be forthcoming about any relevant health issues, as their right to privacy is forfeit in this area as some others.

As headache specialists, we can offer the public our unique perspective and, specifically, insight regarding the impairment that can occur consequent to migraine; but in the end, an accurate appraisal of a given migraineur's physical capacity for discharging competently the responsibilities associated with high office will require adequate (and accurate) disclosure on the part of that individual. Regardless, it seems safe to state that only a small percentage of those actively afflicted with migraine would be unsuited to serve as president on that basis alone.

Federal Funding for Migraine Research

Coverage of the Bachmann/migraine story focused primarily on the political aspects of the issue. Of greater importance to the public (and public health) is our need for more basic research involving migraine and for more effective therapy. The $13 million per year in research funding provided by the National Institutes of Health[65] is inadequate to the task of addressing this disabling and costly disorder that so profoundly affects the lives of so many Americans including presidential candidates, presidents, and first ladies.