We read with great interest and amusement the valiant efforts of Dr. Sheftell et al, to characterize the type of headache experience by JK Rowling's fictional adolescent wizard, Harry Potter.1 In their partially researched report, a diagnosis of “probable migraine” is boldly, albeit limply, offered. Migraine, however, is not a plausible explanation for Harry's headaches.

We, being pediatric neurologists, infinitely more familiar with disorders of muggle children and adolescents, took it upon ourselves to delve more deeply into the nature of Harry Potter's headaches. In addition, we had access to the full 7-volume series of the epic story, and, with special dispensation from the Ministry of Magical Health, were granted exclusive access to review Madame Pomfrey's medical parchments, in accordance with “W” HIPPA regulations.

Several facts are quite clear.

Harry Potter's headaches are clearly secondary headaches and not primary headaches (ie, migraine) as they can be attributed directly to an underlying magical intervention, the spell cast by “He-who-must-not-be-named” when Harry was a young child. Harry's headaches, ergo, are posttraumatic. “He-who-must-not-be-named” attacked young Harry with a death curse causing tissue disruption and a resulting lightning-bolt shaped scar on his right forehead. Harry's last recollection is a bright green flash as the curse struck his head. Fortunately, the major impact was deflected by his mother's protective actions; otherwise, Harry would not have survived this vicious assault.

The pain of Harry's headache occurs episodically and is manifest by a sudden, needle-sharp, burning, shooting pain across the scar on his forehead as though the scar was on fire. The pain is intense, blinding and of such severity that Harry falls to his knees at times with tears streaming down his face. The duration of the pain is brief, gone as quickly comes, but can last up to 2 minutes. Following the pain, the area around the scar is tender and can ache for several minutes.

Curiously, the epochs of pain are triggered by an association with “He-who-must-not-be-named” and a prickling sensation sometimes provides a promontory warning to Harry of Voldemort's presence.

Given the available information, what is the differential diagnosis? In a very general sense, his headaches could be categorized at chronic headache attributed to head or neck trauma (5.6.2) since there is indisputable evidence of head trauma (eg, the lightening bolt shaped scar), the headaches develops in close temporal relation to trauma and the pain has persisted greater than 3 months. Alternatively, given the emotion trauma of the violent deaths of both of his parents at the time of the attack, headache attributed to posttraumatic stress disorder (A12.9) also has merit.

Cluster or paroxysmal hemicrania (ie, trigeminal autonomic cephalalgias) must be considered by virtue of the location, the brevity and clustering of the attacks, as well as the associated autonomic feature, tearing.

An alternative explanation relates to the brief and intense burning nature of the pain, which clearly has a neuropathic quality. This points more toward the group of neuralgiform disorders. With that in mind, one plausible explanation of Harry Potter's headache is trigeminal neuralgia (13.1.1) characterized by paroxysmal attacks, lasting seconds to 2 minutes, of intense, sharp, superficial, or stabbing pain precipated by trigger or trigger factors. One might also consider supraorbital neuralgia (13.6) since the pain is in the region of supraorbital notch and there is often described as tenderness over scar.

The most likely diagnosis, however, given all the facts, and with particular note that the pain arising from the lightening bolt scar itself, is that a neuroma formed in the area of trauma on branches of the first division of trigeminal nerve producing “symptomatic” trigeminal neuralgia (13.1.2). Neuropathic pain is typically burning, electric, or shooting pain and can be caused by pathologic damage to nerves. Additional features include allodynia and hyperalgesia. The most common underlying secondary causes of trigeminal neuralgia include multiple sclerosis, basilar artery aneurysm, arterial or venous compression, syringobulbia, brainstem infarction, and neoplasm (epidermoid, acoustic neuroma, meningioma, or trigeminal neuroma).2 Posttraumatic neuroma formation is a significant cause of neuropathic pain and can occur after elective surgery, amputation, or trauma.3

The most difficult aspect to fully explain is the initiation or activation of Harry's pain when in proximity to “He-who-must-not-be-named.” The pain is also triggered when Harry had intense feelings or recollections of encounters with Voldemort suggesting that there is an unusually strong emotional or psychic component.

Madame Pomfrey's impeccable medical parchments and precise recollections proved to be most invaluable to illuminate our muggle-born minds. A phenomenon not commonly encountered in most pediatric emergency departments is wounds caused by witches or wizard curses. This is rather a common outpatient (or out-wizard/witch) problem at Hogwarts and other schools of wizardry. Novice wizards with short tempers occasionally zap one another with curses leaving minor cutaneous wounds, tissue supplements (ie, pig's tails) or loss of musculoskeletal segments, but the practice of the Dark Arts can produce some quite nasty, life-threatening, lesions. These lesions are notoriously difficult to heal and often leave behind unsightly, slow healing scars.

In the attack on infant Harry, “He-who-must-not-be-named” delivered a partially deflected death curse which back-fired and drew some of Voldemort's own soul into Harry's wound, causing Harry, unknowingly, to become a horcrux himself. This horcrux may represent a magical form of a neuroma. Madame Pomfrey speculated that the presence of “He-who-must-not-be-named” own essence within Harry's scar serves as the principle trigger for Harry's painful attacks when brought into proximity with the whole malevolent entity of Voldemort's remaining soul.

Our final diagnosis then, is “symptomatic” trigeminal neuralgia (13.1.2) due to a posttraumatic neuroma (horcrux) and attributed to magical intervention. Further supportive evidence is supplied in the final chapter of volume 7 in which 19-year longitudinal follow-up is provided. Complete remission is achieved following removal of this “neuroma” during the dramatic, penultimate, clash with Voldemort. Harry no longer experienced his headaches and “all was well.”


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