October 1, 2018History of Medicine
An early description consistent with migraines is contained in the Ebers papyrus, written around 1500 BCE in ancient Egypt. In 200 BCE, writings from the Hippocratic school of medicine described the visual aura that can precede the headache and a partial relief occurring through vomiting. A second-century description by Aretaeus of Cappadocia divided headaches into three types: cephalalgia, cephalea, and heterocrania. Galen of Pergamon used the term hemicrania (half-head), from which the word migraine was eventually derived. He also proposed that the pain arose from the meninges and blood vessels of the head. Migraines were first divided into the two now used types - migraine with aura (migraine ophthalmique) and migraine without aura (migraine vulgaire) in 1887 by Louis Hyacinthe Thomas, a French Librarian.
A trepanated skull, from the Neolithic. The perimeter of the hole in the skull is rounded off by ingrowth of new bony tissue, indicating that the person survived the operation. Trepanation, the deliberate drilling of holes into a skull, was practiced as early as 7,000 BCE. While sometimes people survived, many would have died from the procedure due to infection. It was believed to work via "letting evil spirits escape". William Harvey recommended trepanation as a treatment for migraines in the 17th century.
In the International Headache Society classification of headaches, the concept of aura is given a key role. It serves as a boundary between 'migraine without aura' and 'migraine with aura'. Historically, the concept of an aura was borrowed from the epilepsy vocabulary; a borrowing that took place in English medicine at the beginning of the 19th century and in French medicine in the mid-19th century. It would therefore be interesting to see which features of the epileptic aura are used to explain the migraine aura. Based on the French and English medical literature of the 19th century, two processes have been reviewed: (i) the emergence of the concept of aura, and (ii) the modifications of this concept throughout the 19th century. It appears that the original medical use of the term 'aura' as a set of rising tactile sensations was in use from the 2nd century until late in the 19th century, but then various other symptoms were recognized and the aura gradually became accepted as an early part of the seizure. By the end of the 19th century the aura that preceded a migraine was seen as a similar process, and thought of as part of the migraine sequence. While many treatments for migraines have been attempted, it was not until 1868 that use of a substance which eventually turned out to be effective began. This substance was the fungus ergot from which ergotamine was isolated in 1918. Methysergide was developed in 1959 and the first triptan, sumatriptan, was developed in 1988. During the 20th century with better study design effective preventative measures were found and confirmed. A few centuries ago, people who described an episode of strangely skewed vision followed by a throbbing headache might be told they had received a message from heaven, or else they had been possessed by an evil spirit.
Among the earliest migraine sufferers to record her experience in pictures as well as text was Hildegard von Bingen, a 12th-century German abbess, philosopher, and composer. Like so many migraine sufferers, she was bewildered and frightened at first by the unearthly sights of her migraine aura. Their source was clear to her, however. As someone who from the age of eight spent her life in religious orders, Hildegard naturally saw these visions as glimpses of the divine. Of one episode, she writes:
"I saw a great star, most splendid and beautiful, and with it an exceeding multitude of falling sparks with which the star followed southward and suddenly they were all annihilated, being turned into black coals and cast into the abyss so that I could see them no more."
The jagged edges of a star, flashes of light from moving sparks, and the subsequent blackness - to recognize all these perceptions as typical of a migraine aura does not contradict the profoundly spiritual nature of this sufferer's migraine experiences. Although she did not receive a formal education, Hildegard kept up with the best scientific thinking of her time; she read widely, developed a theory of cosmology, and was known as a gifted herbalist. Simply, the visions of migraine aura carried a religious meaning for her because that was the form her mind imposed on them.
Hildegard of Bingen OSB (German: Hildegard von Bingen; Latin: Hildegardis Bingensis; 1098 - 17 September 1179), also known as Saint Hildegard and Sibyl of the Rhine, was a German Benedictine abbess, writer, composer, philosopher, Christian mystic, visionary, and polymath. She is considered to be the founder of scientific natural history in Germany. Hildegard was elected magistra by her fellow nuns in 1136; she founded the monasteries of Rupertsberg in 1150 and Eibingen in 1165. One of her works as a composer, the Ordo Virtutum, is an early example of liturgical drama and arguably the oldest surviving morality play. She wrote theological, botanical, and medicinal texts, as well as letters, liturgical songs, and poems, while supervising miniature illuminations in the Rupertsberg manuscript of her first work, Scivias. She is also noted for the invention of a constructed language known as Lingua Ignota. Although the history of her formal consideration is complicated, she has been recognized as a saint by branches of the Roman Catholic Church for centuries. On 7 October 2012, Pope Benedict XVI named her a Doctor of the Church. Hildegard was born around the year 1098, although the exact date is uncertain. Her parents were Mechtild of Merxheim-Nahet and Hildebert of Bermersheim, a family of the free lower nobility in the service of the Count Meginhard of Sponheim.
Sickly from birth, Hildegard is traditionally considered their youngest and tenth child, although there are records of seven older siblings. In her Vita, Hildegard states that from a very young age she had experienced visions. Perhaps because of Hildegard's visions, or as a method of political positioning (or both), Hildegard's parents offered her as an oblate to the Benedictine monastery at the Disibodenberg, which had been recently reformed in the Palatinate Forest. The date of Hildegard's enclosure at the monastery is the subject of debate. Her Vita says she was professed with an older woman, Jutta, the daughter of Count Stephan II of Sponheim, at the age of eight. However, Jutta's date of enclosure is known to have been in 1112, when Hildegard would have been fourteen. Their vows were received by Bishop Otto Bamberg on All Saints' Day, 1112. Some scholars speculate that Hildegard was placed in the care of Jutta at the age of eight, and the two women were then enclosed together six years later. In any case, Hildegard and Jutta were enclosed together at the Disibodenberg, and formed the core of a growing community of women attached to the male monastery. Jutta was also a visionary and thus attracted many followers who came to visit her at the cloister. Hildegard tells us that Jutta taught her to read and write, but that she was unlearned and therefore incapable of teaching Hildegard sound biblical interpretation. The written record of the Life of Jutta indicates that Hildegard probably assisted her in reciting the psalms, working in the garden and other handiwork, and tending to the sick. This might have been a time when Hildegard learned how to play the ten-stringed psaltery. Volmar, a frequent visitor, may have taught Hildegard simple psalm notation. The time she studied music could have been the beginning of the compositions she would later create. Upon Jutta's death in 1136, Hildegard was unanimously elected as magistra of the community by her fellow nuns.
Abbot Kuno of Disibodenberg asked Hildegard to be Prioress, which would be under his authority. Hildegard, however, wanted more independence for herself and her nuns, and asked Abbot Kuno to allow them to move to Rupertsberg. This was to be a move towards poverty, from a stone complex that was well established to a temporary dwelling place. When the abbot declined Hildegard's proposition, Hildegard went over his head and received the approval of Archbishop Henry I of Mainz. Abbot Kuno did not relent until Hildegard was stricken by an illness that kept her paralyzed and unable to move from her bed, an event that she attributed to God's unhappiness at her not following his orders to move her nuns to Rupertsberg. It was only when the Abbot himself could not move Hildegard that he decided to grant the nuns their own monastery. Hildegard and about twenty nuns thus moved to the St. Rupertsberg monastery in 1150, where Volmar served as provost, as well as Hildegard's confessor and scribe. In 1165 Hildegard founded a second monastery for her nuns at Eibingen.
Hildegard said that she first saw "The Shade of the Living Light" at the age of three, and by the age of five she began to understand that she was experiencing visions. She used the term 'visio' to this feature of her experience, and recognized that it was a gift that she could not explain to others. Hildegard explained that she saw all things in the light of God through the five senses: sight, hearing, taste, smell, and touch. Hildegard was hesitant to share her visions, confiding only to Jutta, who in turn told Volmar, Hildegard's tutor and, later, secretary. Throughout her life, she continued to have many visions, and in 1141, at the age of 42, Hildegard received a vision she believed to be an instruction from God, to "write down that which you see and hear." Still hesitant to record her visions, Hildegard became physically ill. The illustrations recorded in the book of Scivias were visions that Hildegard experienced, causing her great suffering and tribulations. In her first theological text, Scivias ("Know the Ways"), Hildegard describes her struggle within:
But I, though I saw and heard these things, refused to write for a long time through doubt and bad opinion and the diversity of human words, not with stubbornness but in the exercise of humility, until, laid low by the scourge of God, I fell upon a bed of sickness; then, compelled at last by many illnesses, and by the witness of a certain noble maiden of good conduct [the nun Richardis von Stade] and of that man whom I had secretly sought and found, as mentioned above, I set my hand to the writing. While I was doing it, I sensed, as I mentioned before, the deep profundity of scriptural exposition; and, raising myself from illness by the strength I received, I brought this work to a close - though just barely - in ten years. (...) And I spoke and wrote these things not by the invention of my heart or that of any other person, but as by the secret mysteries of God I heard and received them in the heavenly places. And again I heard a voice from Heaven saying to me, 'Cry out therefore, and write thus!'
It was between November 1147 and February 1148 at the synod in Trier that Pope Eugenius heard about Hildegard's writings. It was from this that she received Papal approval to document her visions as revelations from the Holy Spirit giving her instant credence. On 17 September 1179, when Hildegard died, her sisters claimed they saw two streams of light appear in the skies and cross over the room where she was dying. Hildegard's works include three great volumes of visionary theology; a variety of musical compositions for use in liturgy, as well as the musical morality play Ordo Virtutum; one of the largest bodies of letters (nearly 400) to survive from the Middle Ages, addressed to correspondents ranging from popes to emperors to abbots and abbesses, and including records of many of the sermons she preached in the 1160s and 1170s; two volumes of material on natural medicine and cures; an invented language called the Lingua ignota ("unknown language"); and various minor works, including a gospel commentary and two works of hagiography.
Several manuscripts of her works were produced during her lifetime, including the illustrated Rupertsberg manuscript of her first major work, Scivias (lost since 1945); the Dendermonde Codex, which contains one version of her musical works; and the Ghent manuscript, which was the first fair-copy made for editing of her final theological work, the Liber Divinorum Operum. At the end of her life, and probably under her initial guidance, all of her works were edited and gathered into the single Riesenkodex manuscript. Hildegard's most significant works were her three volumes of visionary theology. In these volumes, the last of which was completed when she was well into her seventies, Hildegard first describes each vision, whose details are often strange and enigmatic, and then interprets their theological contents in the words of the "voice of the Living Light." The composition of the first work, Scivias, was triggered by the insistence of her visionary experiences in about 1142, when she was already forty-three years old. Perceiving a divine command to "write down what you see and hear", Hildegard began to record her visionary experiences. Scivias is structured into three parts of unequal length. The first part (six visions) chronicles the order of God's creation: the Creation and Fall of Adam and Eve, the structure of the universe (famously described as the shape of an "egg"), the relationship between body and soul, God's relationship to his people through the Synagogue, and the choirs of angels. The second part (seven visions) describes the order of redemption: the coming of Christ the Redeemer, the Trinity, the Church as the Bride of Christ and the Mother of the Faithful in baptism and confirmation, the orders of the Church, Christ's sacrifice on the Cross and the Eucharist, and the fight against the devil. Finally, the third part (thirteen visions) recapitulates the history of salvation told in the first two parts, symbolized as a building adorned with various allegorical figures and virtues. It concludes with the Symphony of Heaven, an early version of Hildegard's musical compositions.
In her second volume of visionary theology, composed between 1158 and 1163, after she had moved her community of nuns into independence at the Rupertsberg in Bingen, Hildegard tackled the moral life in the form of dramatic confrontations between the virtues and the vices. Amongst the work's innovations is one of the earliest descriptions of purgatory as the place where each soul would have to work off its debts after death before entering heaven. Hildegard's descriptions of the possible punishments there are often gruesome and grotesque, which emphasize the work's moral and pastoral purpose as a practical guide to the life of true penance and proper virtue. Hildegard's last and grandest visionary work had its genesis in one of the few times she experienced something like an ecstatic loss of consciousness. As she described it in an autobiographical passage included in her Vita, sometime in about 1163, she received "an extraordinary mystical vision" in which was revealed the "sprinkling drops of sweet rain" that John the Evangelist experienced when he wrote, "In the beginning was the Word" (John 1:1). Hildegard perceived that this Word was the key to the "Work of God", of which humankind is the pinnacle. The "Book of Divine Works", therefore, became in many ways an extended explication of the Prologue to John's Gospel.
The ten visions of this work's three parts are cosmic in scale, often populated by the grand allegorical female figures representing Divine Love (Caritas) or Wisdom (Sapientia). Attention in recent decades to women of the medieval Church has led to a great deal of popular interest in Hildegard's music. In addition to the Ordo Virtutum, sixty-nine musical compositions, each with its own original poetic text, survive, and at least four other texts are known, though their musical notation has been lost. This is one of the largest repertoires among medieval composers. One of her better known works, Ordo Virtutum (Play of the Virtues), is a morality play. It is uncertain when some of Hildegard's compositions were composed, though the Ordo Virtutum is thought to have been composed as early as 1151. The morality play consists of monophonic melodies for the Anima (human soul) and 16 Virtues. There is also one speaking part for the Devil. Scholars assert that the role of the Devil would have been played by Volmar, while Hildegard's nuns would have played the parts of Anima and the Virtues. In addition to the Ordo Virtutum, Hildegard composed many liturgical songs that were collected into a cycle called the Symphonia armoniae celestium revelationum. The songs from the Symphonia are set to Hildegard's own text and range from antiphons, hymns, and sequences, to responsories. Her music is described as monophonic, that is, consisting of exactly one melodic line. Its style is characterized by soaring melodies that can push the boundaries of the more staid ranges of traditional Gregorian chant. The reverence for the Virgin Mary reflected in music shows how deeply influenced and inspired Hildegard of Bingen and her community were by the Virgin Mary and the saints.
Those who have experienced them know that migraines are all too real. Making sense of them is a major challenge, however. They are made even more baffling by the fact that the headache is not their only manifestation. Migraines are often preceded or accompanied by visual hallucinations. Arriving suddenly out of a clear blue sky, a migraine aura - a set of shimmering, flashing, weird perceptions - is bound to seem inexplicable, even frightening. This was certainly the case for eminent neurologist Oliver Sacks, whose first migraine occurred when he was only three or four years old. The incident left an indelible memory:
"I was playing in the garden when a brilliant, shimmering light appeared to my left?dazzlingly bright, almost as bright as the sun. It expanded, becoming an enormous shimmering semicircle stretching from the ground to the sky, with sharp zigzagging borders and brilliant blue and orange colors. Then, behind the brightness, came a blindness, an emptiness in my field of vision, and soon I could see almost nothing on my left side. I was terrified?what was happening? My sight returned to normal in a few minutes, but those were the longest minutes I had ever experienced."
Fortunately for young Oliver, his mother immediately recognized the condition. As a migraine sufferer herself, and a trained physician, she could assure him he would soon be good as new. She explained he had experienced "a sort of disturbance like a wave" passing across a part of his brain, temporarily distorting his senses. Years later, Oliver Sacks wrote a book, Migraine, and a number of related articles that greatly increased the public understanding of migraine - not just the headache but also the aura and other characteristic symptoms - as an illness, and a fairly common one at that. According to figures from the World Health Organization, as many as 11 percent of all adults suffer from this condition, which affects their quality of life and interferes with work and social activities. The toll on the affected individual amounts to an estimated 1.3 years lost to disability over a lifetime. In trying to identify the cause of migraines and the sensory havoc that comes with them, patients and healthcare professionals have pointed to a great variety of factors: coffee, red wine, aged cheese, sunlight, exercise or lack of exercise, fluctuating hormone levels, chronic stress. Although a discrete episode of migraine might be triggered by any of these, or even by no apparent factor at all, the underlying susceptibility to migraines seems to be encoded in the genome. In studies focusing on the so-called classic manifestation, migraine with aura, researchers have identified mutations in several genes that are involved in the release and uptake of two important signaling molecules in the synapses between brain cells. One of these chemical signals, or neurotransmitters, is serotonin, which helps regulate sleep and mood and is also involved in the perception of pain. The other neurotransmitter, glutamate, serves as an excitatory signal, enabling the physical processes in the brain that underlie learning and memory. Too much excitement can be dangerous, however: Although under normal circumstances glutamate acts as the on signal for many brain activities, over-exposure to glutamate may cause receptor cells to shut down altogether for a time, or even die.
A recent study in Nature Genetics suggests that if neurons at the receiving end of a glutamate signal do not perform efficiently, an accumulation of glutamate in the synapses may help bring on migraine attacks. The wave of hyper-excitement followed by inactivity spreads across the cerebral cortex and gradually disperses like ripples on the surface of a pond, in a feature known as cortical spreading depression. Depending on which regions of the brain it affects, cortical spreading depression can wreak mischief on the senses in myriad ways, in addition to the most common visual auras. Journals of neurology abound with case histories of hallucinatory sounds, illusory odors (usually unpleasant, alas), dizziness, tingling, numbness, or out-of-body experiences.
Oliver Sacks, in his book Migraine, called Hildegard von Bingen's visions "indisputably migrainous," but stated that this does not invalidate her visions, because it is what one does with a psychological condition that is important. The resemblance of the illuminations to typical symptoms of migraine attacks, especially in cases where it is not precisely described in the text, is one of the stronger arguments that Hildegard herself was directly involved in their creation. Dr. Sacks and other diagnosticians of history of migraine, do not suggest that great artistic achievement is of a lesser nature, when the creator suffers from migraine. It is not known what the connection (if any) is between migraine and creativity. It has also been suggested that the visions may have been due to hallucinogenic components present in ergot, common in that area of the Rhineland, at certain times of the year.