Abstract
Dear Sir,
Neurology is not a developed specialty in Myanmar. There are 10 neurologists for 55 million people. Most are working in Yangon, the largest city with 7 million people; they have positions in university hospitals or are retired. The retirement age is 60. Since a professor in neurology cannot live suitably on an academic salary, several, if not all, government-funded specialists are working in private practice after regular office hours. Myanmar neurologists can see more than 100 patients a day in private clinics, but the vast majority of patients with diseases of the nervous system never see a neurologist — they are treated by internists, general practitioners and by physicians practicing traditional medicine.
There are no health insurance companies in Myanmar. Government health care is delivered on a cost-sharing basis where, generally speaking, primary care and consultations provided by a specialist physician are paid by the government; however, most investigations and treatment are paid for by the patient. Our experience comes partly from our work in a charity clinic in Jivitadana Sangha Hospital and partly from a private clinic in Pun Hlaing Hospital, which is fee-for-service (cash-paid).
There are many private clinics in Yangon, and specialists travel around to several clinics daily for patient evaluations. There is no electronic medical record. Instead, the medical records are small handwritten books with notes and prescriptions. The system is convenient as the patients themselves carry their books, lab results and X-ray films. This medical record system gives us a good insight into how neurology is practiced since most of our patients have previously been evaluated by other neurologists.
We have access to computed tomography (CT) ($100 USD), magnetic resonance imaging (MRI) ($200 USD) and electroencephalography (EEG) ($25 USD); other electrophysiological investigations are not available; all investigations are paid for by the patient. Requests for consultation for all major neurological diseases are evident in Myanmar, including vascular diseases in the brain (often in younger patients), epilepsy, primary brain tumours and neurodegenerative diseases. We have seen only three patients with multiple sclerosis. With this exception, the prevalence of neurological disorders presented to us is otherwise not significantly different from that seen in a clinic in Scandinavia.
As such, headache is a common patient complaint in our neurological practice. In Yangon General Hospitals’ (YGH) outpatient clinic, after cerebrovascular consultations (20%), patients with a chief complaint of headache represent the second-most common referral (19%). Headache medicine is not a well-developed specialty from a practical or conceptual standpoint. While the term primary headache is known, the concept is only loosely, if at all, implemented in clinical practice.
The most common diagnosis in practice is headache, unspecified, and headache is generally considered to be a secondary phenomenon, usually caused by high blood pressure (even slight increases in blood pressure are considered to have a causal relationship with headache), a refractive error, or as a somatic manifestation of an anxiety or personality disorder.
Propranolol, valporate, gabapentin, topiramate, flunarazine, amitriptyline and selective serotonin reuptake inhibitors (SSRIs) are available. Acetylsalicylic acid and ergotamine tartrate is used very little. Sumatriptan is now available in Yangon. Headache is usually treated with a low dose of analgesic; if that does not help, the general practitioner usually prescribes a diclofenac injection. Many patients treat headache by applying a little plaster with a cream to the temporal regions that induces a local burning sensation. In that way patients can signal to others that they are experiencing a headache.
If prophylactic treatment is used, valporate (200 mg/day) or Gabapentin (300 mg/day) or flunarazine (5 mg/day) are the drugs of choice. Neutriceuticals and ‘health-promoting tablets’ are popular amongst the Myanmar population, and some are sceptical of ‘English medicine’.
Approximately 42% of all patients come or are referred to our clinic because they suffer from problems they locate to the head. The diagnoses according to the International Classification of Headache Diseases (ICHD-II) are tension-type headache (13%) (2.1 through 2.4.3) migraine (9%) (ICHD-II; 1.1, 1.2.1, 1.2.3, 1.2.6; cases of 1.3.3 in adults, and one case of 1.4 – as well as patients in the 1.6 group); one single patient with episodic cluster headache (ICHD-II 3.1) and one with chronic paroxysmal hemicrania, (ICHD-II 3.2.2). Facial pain is seen in 3% of our patients referred with head pain, including trigeminal neuralgia (ICHD-II 13.1 and 13.1.4). Of note, we have not seen more than a single patient with medication overuse headache (ICHD-II 8.2). Two per cent of our patients were suffering from vertigo (benign paroxysmal positional vertigo, Méniére’s disease and vestibular neuronitis).
However, this leaves 14% of patients referred with problems related to the head unaccounted for and not conforming to any diagnostic category. They all primarily complained of ‘Mude’: The consultation begins typically: ‘How can I help you?’ ‘I am suffering from Mude’. Mude means, according to the Myanmar-English dictionary: Dizziness, drunk.
These patients describe Mude as a disabling condition with ‘dizziness’ without any vertigo or any actual disorder of equilibrium, and ‘cloudiness of the mind and concentration dysfunction’, which forces them to withdraw from daily activities. The condition can occur in episodes lasting from minutes to days, or as a chronic continuous condition which fluctuates in severity. The discomfort is increased by mental and physical activities. Ninety per cent of these patients are female and 25% have a family history of Mude.
The condition can be associated with nausea, blurring of vision, sensory disturbances, photophobia, phonophobia and even stereotyped premonitory symptoms such as yawning. Some of these patients are also suffering from headache on other occasions, often tension-type. Mude is considered to be due to cervical spondylosis. We started to treat it as migraine since the clinical phenotype, absent the headache, is similar to all other patients who present with otherwise typical migraine without aura. The therapeutic response in these patients mirrors the response seen in patients with a more typical phenotype. In fact, our success in treating Mude has earned one of us the reputation of being a Mude specialist.
We can only speculate if Mude is exclusively a Myanmar condition or just unrecognized as a ‘migraine equivalent’ in developed nations. We are, practicing in a Buddhist country, well aware of the fact that there is neither a psyche nor a soul; all manifestations of the human brain are caused by activity in neuronal networks. It is tempting to take a Jacksonian approach and classify this large percentage of our patients with poorly understood disorders located to the head, including migraine, together into one group of functional disorders of neuronal networks, disorders sharing some common basic mechanisms. We are using the word functional as John Hughlings Jackson did: ‘I use the word functional in its meaning as adjective to the word function. I do not believe that there can be any kind of symptoms without abnormal changes, however slight they may be in some cases’. Perhaps the Myanmar patient is teaching us an important neurological lesson with clinical, scientific, and therapeutic implications — that ambiguous, non-specific, neurological symptoms, with or without headache, is a functional disorder that is similar in many ways to migraine.