Abstract
A very recent study has reported a considerable amount of deaths attributed to traumatic head injury in the popular television series ‘Game of Thrones’ (GoT). 1 On second view, reanalysing this television series in detail reveals that some characters actually survived head trauma. Headache, however, plays only a marginal role in the ‘Song of Ice and Fire’. Merrett Frey occasionally suffers from ‘headache building up behind his eyes’ and then a ‘thunderstorm raging between his ears’ that makes him ‘rest on his bed in a dark room’. 2 Ser Gregor Clegane, the ‘Mountain’, suffers from ‘blinding headaches’ and in treating them ‘quaffs the milk of the poppy as lesser men quaff ale’. 3 Other than that, ‘headaches’ are usually only mentioned as a metaphor for nuisances. This is surprising when considering the unprecedented amount of traumatic head injury involving swords, stones, axes, knives, various body parts (of various species including dragons), clubs, hammers, a chamber pot in one incidence, rudders, helmets, body armour, tent poles, wooden logs, fists (in one occasion with a golden hand) and various other (in some instances unspeakable) things, none of the affected people ever complained about post-traumatic headache (PTH).
This is remarkable, since the scientific literature reports prevalence rates as high as 90% of PTH for patients suffering traumatic brain injury 4 and from the fighting we are presented with week by week and the frequent deaths following head injury, 1 there is to be assumed an enormous amount of traumatic brain injury in GoT.
The IHS classification 5,6 differentiates between two types of PTH: acute and persistent headache attributed to traumatic injury to the head. Acute PTH has – apart from the occurrence of a traumatic head injury – to fulfil the following two criteria: (1) the headache has to develop within 7 days after the full ability to perceive pain following the injury has been regained and (2) either the headache has subsided within 3 months following its onset or at the time of diagnosis or 3 months have not yet passed since the headache began. For persistent headache following traumatic injury to the head, criterion (1) is identical, but the headache lasts longer than 3 months following its onset. Both must not be better accounted for by another ICHD diagnosis. 5 Rates of PTH range from 30% to about 90% of patients suffering traumatic brain injury, and in about 20–40% of these, the headache lasts longer than 1 year. 7 –9 Thus, PTH is an important problem in a vast number of patients following traumatic head injury. Clinical features vary, but it is remarkable that especially the persistent form often presents with migraine features. 10
Regarding pathophysiological mechanisms of PTH, the causes are not known. However, the most common theories derive from animal studies and mainly point towards upregulation of inflammatory cascades following traumatic brain injury. Thus, changes of inflammatory cells and mediators including activation of microglia, astrocytes and dural mast cells as well as tumour necrosis factor α and matrix metalloproteinases have been observed in animal models of traumatic brain injury. 4 Most importantly, traumatic brain injury in animal models increases the levels of calcitonin gene-related peptide (CGRP) mRNA 11 – CGRP is nowadays commonly seen as a key mediator of primary headache disorders such as migraine or cluster headache. Additionally, there are some reports of PACAP 38 and BDNF involvement. In general, it is hypothesized that these changes in inflammatory cascades and mediators might lead to sensitization of both central and peripheral pain processing pathways, which leads to behavioural changes measurable in animal models of traumatic brain injury and both cephalic and extra-cephalic allodynia in humans with chronic pain following traumatic brain injury. 4
So why is it that in GoT PTH is hardly ever reported? One obvious reason might be that in a world of medieval appearance without any comforts of today’s medical advances, long-term survival rates following traumatic brain injury may be much lower – thus it is just a logical assumption that the overall prevalence of acute and possibly persistent PTH is also lower. In general, one can rightfully assume that the people of Westeros had to either suffer through the acute stage without adequate medical help or die. 12 The survivors, however, are somewhat unrealistically portrayed. Another example is that Jaime Lannister (affectionately named Kingslayer) never reported phantom pain although he lost his right arm rather early in the series. The authors have to conclude that watching this series may lead to the false impression that brute force to the head (if survived) has no consequences.
These data suggest, to the best of our knowledge, that the series GoT is after all not a realistic documentary and should perhaps be seen as fiction. It is indeed grossly unrealistic that a blunt trauma to the head from a dragon wing does not lead to headache as a consequence. We believe that GoT-related books, films and all merchandising should feature a warning banner quoting ‘Warning! Do not perform at home as this may have serious side-effects’. Or something alike.
Winter is coming!
Responses and letters to the editor are encouraged.
