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Headache for History Buffs
That so many theories to explain the origins of headache have been advanced and rejected over the centuries indicates both its long enduring impact on society’s health and well- being and man’s determination to understand the condition and so rid himself of its burden. Happily, we no longer bore holes into the skulls of headache sufferers so as to release the evil spirits, humors, or vapors accumulated within, and our therapies today are considerably more effective as well as less invasive. The path from “there to here” is a fascinating one;
the personalities of the individuals who have shaped head- ache theory often have been as brilliantly compelling as their theories have been wrong-headed. In this chapter we will trace that path.
Even today, individuals with chronic headache too often are informed that their pain is due to “stress,” anx- iety, depression, or some less well-defined deficiency of
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personality, mood, or behavior. It understandably is dif- ficult for headache sufferers to accept the erroneous no- tion that “it’s all in their heads,” especially when lying in bed in a dark room and desperately trying not to vomit. Many explanations for the cause of headache have been advanced in the past, and it is interesting to speculate whether those actually experiencing the symptom have accepted these frequently wild-eyed theories.
Primitive medicine originated from magical and reli- gious beliefs. Early medical treatments applied not to mind or body alone, but always to both. Ceremonies, prayers, chants, and sacred dances were coupled with massage, sweat baths, purgatives, and incense inhalants to relieve both psychological and physical symptoms.
Drugs were believed to derive their healing power from the incantations that accompanied their administration;
adding a physical manipulation was felt to offer an even greater chance of success. Such interventions were uti- lized to treat headache.
Headache clearly has existed as long as mankind.
The first written descriptions of head pain date from Mesopotamian tablets inscribed around 4000 BC. Demons commonly were thought to be the bearers of headache, and an early description of the evil headache spirit, Ti’u, chasing a victim through the desert, demonstrates vividly the eerie power attributed to this symptom.
Headache roameth over the desert, blowing like the wind,
Flashing like lightning, it is loosed above and below;
It cutteth off him who feareth not his god like a reed,
Like a stalk of henna it shitteth his Chews.
It wastes the flesh of him who hath no protecting goddess,
Flashing like a heavenly star, it cometh, like the dew;
It standeth hostile against the wayfarer, scorching him like the day,
This man it hath struck and
Like one with heart disease he staggereth, Like one bereft of reason he is broken,
Like that which has been cast into the fire he is shriveled,
Like a wild ass . . . his eyes are full of cloud, On himself he feedeth, bound in death;
Headache whose course like the dread windstorm none knoweth,
None knoweth its full time or its bond.
An exorcism was definitely in order for the unfortu- nate soul who had so angered the gods. In combination with an ointment of human bone reduced to ashes and mixed with cedar oil, the priest-physician would use charms and amulets to enact the ritual. Unpleasant sub- stances also were applied, all in hopes of placating the spirits and releasing the headache to move elsewhere.
Other ancient descriptions are more reminiscent of modern headache classifications. One may have been re- ferring to a variant of cluster: “a man’s brain contains fire, and myalgia afflicts the temples and smites the eyes, his eyes are afflicted with dimness, cloudiness, a dis- turbed appearance, with the veins blood-shot, shedding tears.” Another appears to speak to migraine: “when his brow pains a man and he vomits and is sick, his eyes be-
ing inflamed.” In this case the cause of headache is thought to be the “hand of a ghost.”
The Egyptians of old were not unaware of headache.
Gods such as Horus and Ra were known to suffer the disorder, and the goddess Isis treated Ra with a potion of coriander, wormwood, juniper, honey, and opium. A dancing girl in Pharaoh’s court is mentioned in the Eber’s papyrus as having been afflicted with unilateral (one- sided) headaches accompanied by vomiting and malaise, symptoms highly suggestive of migraine. Headache treatments employed by Egyptian physicians included trephining, which involved boring a hole in the skull such
“that the evil air may breathe out.” Less invasive reme- dies including application of wet, cold mortar pressed to the scalp, or of clay crocodiles bearing the names of the gods, bound firmly to the patient’s head with linen strips.
Conceivably these clay totems compressed the superfi- cial temporal arteries, the blood vessels of the temple that so often pound and ache during a migraine, and thus provided relief. Incredibly, to this day preindustrial so- cieties still trephine skulls to relieve chronic headache.
In 400 BCthe Greek physician, Hippocrates, was the first to suggest that the cause of headache was something other than the anger of the gods. He believed head pain occurred when the different elements of nature—blood, phlegm, and black bile—were out of harmony, an exten- sion of the so-called humoral theory of illness. Pain sup- posedly resulted from vapors rising to the head from a bilious liver, and treatment consequently consisted of bloodletting or applying herbs to the scalp so as to drain the excess liquids. We give credit to Hippocrates for rec- ognizing that there are different kinds of headaches, such
as those associated with fever or infection as opposed to primary headaches. An example of the latter follows: “He seemed to see something shining before him like a light, usually in part of the right eye; at the end of a moment, a violent pain supervened in the right temple, then in all the head and neck. Vomiting, when it became possible, was able to divert the pain and render it more moder- ate.” This patient appears to have had migraine, his symptoms including a visual aura immediately prior to headache onset.
The Navaho people today still employ ancient cere- monies to cure disease. They believe that the sufferer needs to restore harmony with nature, and they empha- size the inclusion of family and friends to achieve this end. The cause of illness may be a broken taboo or some other offense against the gods, and during a typical cer- emony, the gods are petitioned to forgive the transgres- sion. Purgatives, emetics, and sweat baths are physical treatments utilized, while the gods hear chants and view the sand paintings offered as appeasement for misdeeds.
This method demonstrates well an example of “holistic”
medicine, involving the simultaneous treatment of both body and mind.
Four hundred years after Hippocrates, Aretaeus of Cappadocia (AD 30–90) classified three distinct types of headache; one, called “heterocrania,” encompassed the constellation of symptoms we term “migraine.” Hetero- crania lasted from 6 to 24 hours and consisted of one- sided throbbing head pain, gastric upset, and sensitivity to light, sound, and smells. Aretaeus proposed treatment based on the theory that counterirritants would dispel the headache. Substances such as pitch were lathered
onto a shaved head to raise blisters and thus rid the sufferer of internal head pain. It is difficult to imagine that this health care intervention yielded many return customers.
In Roman times the physician Galen (AD 131–201) used the Greek word “hemicrania” (meaning half the head) to describe these headaches. Hemicrania translated to the Latin “hemicranium,” eventually evolving to be- come “emigranea” and then “mygraine” and “megrim”
in English. These terms refer to the “sick headaches” of migraine. Influenced by the writings of Hippocrates, Galen thought their cause to be bilious vapors carried by blood vessels from body to brain. To treat these attacks, he recommended bloodletting and application of local cold packs. Like Aretaeus, he believed counterirritants to be useful and advocated placing a live electric fish, called a torpedo, on the forehead. As had the Egyptians, Galen also treated “hemicrania” with narcotics such as opium and mandragora.
The importance of trigger factors in precipitating mi- graine was documented by the Romans. Celsus (25 BCto AD 50) wrote that “wine, cold, heat of fire, or the sun”
could bring on a headache, furthermore noting that mi- graine was not fatal and tended to run a chronic, episodic course throughout one’s life span. Headache is men- tioned in the Talmud, a collection of rabbinical discus- sions of biblical law compiled during the second through sixth centuries, and was linked to one’s blowing away the foam of drinks like beer or mead; indirectly, at least, alcohol thus was identified as a trigger. Talmudic writ- ings also convey the belief that headaches result from sin- fulness and may be cured by penitence and the perfor-
mance of good works. For those less inclined to acts of redemption, rubbing the head with wine, vinegar, or oil was available as an alternative treatment. Moses Mai- monides, physician and spiritual leader of the Egyptian Jewish community in the twelfth century, believed, as did Galen, that headaches were due to dysequilibrium of body humors and championed preventive therapy, such as a healthy diet and exercise to treat illness. He also rec- ommended more specific remedies such as binding the temples, bloodletting from the pulsing arteries behind the ears, and vomiting twice a month to purge the system.
The first to mention headache as a symptom of oc- cupational illness was Bernardo Ramazzini. In his trea- tise entitled “De Tomhis artificum diatriba,” published in 1700 at the University of Modena, he listed twelve pro- fessions predisposing to chronic headache (pharmacist, oil-miller, tanner or other grimy craftsman, tobacco worker, wet nurse, brewer of alcoholic beverages, tailor, wool carrier, miner, scribe or stenographer, confectioner who sugar-coated seeds over burning coal, carpenter, sailor or galley slave, and hunter.) Ramazzini believed that the majority of these professions caused headache via the inhalation of noxious vapors and, in the case of coal, a toxic carbon oxide gas. For desk workers and seamstresses, he attributed their suffering to long hours of intense concentration under wretched environmental conditions, resulting in what we now would term ten- sion-type headache. Sailors and hunters were felt to ex- perience headache in reaction to changes in temperature and sun exposure, while wet-nurses developed headache from fatigue associated with sleep deprivation. Some professionals, such as singers and musicians, engaged in
activities which presumably aggravated preexisting headache disorders by forcibly and repeatedly contract- ing their abdominal and pectoral muscles, which affected the flow of blood to the head. Suggested therapies included removal of noxious odors and better hygiene within the workplace. For pharmacists, he wrote, “those in whom the power of scent of dogs resides should run away from such smells as far as possible, and again and again go out of the shop to breath fresh air, or very of- ten hold more welcome scents to their noses, by which they may regularly obtain relief, and blunt the offending smells.” Excessively stated, perhaps, but identification of headache triggers in the workplace remains an important consideration in the modern management of migraine.
The next advance occurred in seventeenth-century England, when Dr. Thomas Willis proposed that the headache of “megrim” derived from swollen blood ves- sels that expanded within the head caused a throbbing pain. He further suggested that this disturbance of nor- mal vascular functioning originated in the brain itself. No techniques were available at that time to prove his the- ory, and it was not until the twentieth century that evi- dence emerged to support a primary vascular hypothe- sis. Willis used ointment of quick-silver, mercurial powder, and spa waters to treat headache but admitted that “For the obtaining a Cur, or rather for a tryal very many Remedies were administered, throughout the whole progress of the Disease, by the most skilful Physi- cians . . . without any success or ease.”
In the late 1700s Erasmus Darwin, physician and grandfather of naturalist Charles Darwin, also proposed
that migraine headaches were due to dilatation of brain blood vessels, and from this followed what seemed a log- ical, albeit dramatic treatment: patients were spun in a large centrifuge to force blood from the head to the feet and relieve the vascular swelling. This probably did re- sult in the patient experiencing a renewed sense of well- being . . . if only because the spinning finally stopped.
During the next two centuries, physicians described many different factors that could influence the develop- ment of headaches: diet, underlying psychological diffi- culties, fluctuations of ovarian function and gastroin- testinal disturbances. In 1873 Dr. Edward Liveing wrote On Megrim, Sick-Headache, and Some Allied Disorder, de- scribing in detail the faulty habits of life that caused the illness. He recommended an improved diet, restoration of general health through rest and good personal hygiene and the use of sedatives such as belladonna, “tonics,”
iron, and quinine.
Toward the end of the 1800s, exploration of the causes of tension-type headache received particular attention from physicians. Victorian neurologists attributed these headaches to overintense mental concentration, hysteria, or hypochondria. Treatments ran the gamut from bed rest to vigorous exercise, and medicines included laudanum and hemp. Sigmund Freud, physician and founder of modern psychoanalysis, wrote that the logical center for migraine was the “trigeminal nucleus whose fibers sup- ply the dura mater” and “may include spastic innerva- tion of muscles of blood vessels in the reflex sphere of the ductal region.” This anticipated the current theory of Moskowitz, proposing that abnormally dilated menin-
geal vessels (blood vessels on the outside of the brain) emit signals that stimulate trigeminovascular neurons to produce migraine.
The twentieth-century physician William Osler first introduced the idea that the muscles of the head were ab- normally tense during headache. Wolff studied this and purported to show that involuntary contraction of scalp and neck muscles did cause headache; he called this
“muscle-contraction” headache. More recent studies show no consistent correlation between “tension-type”
headache and muscle contraction. While many individ- uals with “pure” tension-type headache are commonly found in the general population, the spectrum of head pain suffered by migraineurs runs the gamut from the mildest tension-type headache to functionally disabling, commode-hugging head pain of such miserable intensity that death may seem preferable. Interestingly, the ten- sion-type headaches experienced by those with “pure”
tension-type headache are typically unresponsive to medications designed for migraine, while those medica- tions are effective for the tension-type headaches experi- enced by migraineurs. Thus, it may be that a single head- ache type may arise from very different biologic sources.
Misery loves company, and it may help the mi- graineur to feel less picked upon to know that many fa- mous persons also suffered from headache. Among them are former U.S. presidents Ulysses S. Grant (Appendix I) and Thomas Jefferson; writers Guy de Maupassant, Edgar Allan Poe, Leo Tolstoy, Virginia Woolf, and Lewis Carroll; scientists Carl Linnaeus, Charles Darwin, and Sigmund Freud; philosophers Immanuel Kant and Karl Marx; Julius Caesar, Mary Todd Lincoln and Madame de
Pompadour. The less noteworthy are, of course, often af- flicted as well; of this book’s authors, Drs. Rothrock and Mark Green have migraine.
Research intended to reveal the origins of headache continues to advance, and the greater knowledge derived will help us to develop rational, safer, and more effective therapies. Regardless, the past has much to teach us; in attempting to subdue headache, one should not lose sight of the powerful effect of applying any remedies at- tempted to both mind and body.
