Target Health Blog

Migraines

July 23, 2018

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History of Medicine
Source:

The Head Ache, George Cruikshank (1819); Painting credit: George Cruikshank - http://metmuseum.org/art/collection/search/393320, Public Domain, https://commons.wikimedia.org/w/index.php?curid=251827

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.

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. 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.

Reminiscences of Oliver Sacks MD

Oliver Sacks MD (1933 - 2015); Photo credit: Luigi Novi / Wikimedia Commons, CC BY 3.0,https://commons.wikimedia.org/w/index.php?curid=7815388

I have had migraines for most of my life; the first attack I remember occurred when I was 3 or 4 years old. 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 these were the longest minutes I had ever experienced. I told my mother what had happened, and she explained to me that what I had had was a migraine - she was a doctor, and she, too, was a migraineur. It was a “visual migraine,“ she said, or a migraine “aura.“ The zigzag shape, she would later tell me, resembled that of medieval forts, and was sometimes called a “fortification pattern.“ Many people, she explained, would get a terrible headache after seeing such a “fortification“ - but, if I were lucky, I would be one of those who got only the aura, without the headache. I was lucky here, and lucky, too, to have a mother who could reassure me that everything would be back to normal within a few minutes, and with whom, as I got older, I could share my migraine experiences. She explained that auras like mine were due to a sort of disturbance like a wave passing across the visual parts of the brain. A similar “wave“ might pass over other parts of the brain, she said, so one might get a strange feeling on one side of the body, or experience a funny smell, or find oneself temporarily unable to speak. A migraine might affect one's perception of color, or depth, or movement, might make the whole visual world unintelligible for a few minutes. Then, if one were unlucky, the rest of the migraine might follow: violent headaches, often on one side, vomiting, painful sensitivity to light and noise, abdominal disturbances, and a host of other symptoms.

Source: Patterns by Oliver Sacks MD

On 30 September 1858, Sir John Herschel (1792-1871), mathematician, astronomer, chemist and photographer, gave a lecture on 'Sensorial Vision' to the gathered members of the Leeds Philosophical Society. He told how one morning, at his breakfast table, he had watched a 'singular shadowy appearance' at the outside corner of his left field of vision. The pattern appeared 'in straight-lined angular forms, very much in general aspect like the drawing of a fortification, with salient and re-entering angles, bastions and ravelins, with some suspicion of faint lines of color between the dark lines'. Herschel was not alone in publicly recording such a personal experience. In 1865, David Brewster, natural philosopher and inventor of the kaleidoscope, discussed his experiences of ocular spectra, this time in the Philosophical Magazine as a way to contribute to theories about the structure of the optic nerve. Later the same year, the Astronomer Royal, George Biddell Airy, also published an account of his periodic attacks of hemiopsy. In these papers, these men of science did not tend to dwell on other forms of pain or suffering associated with their visual disturbance. Brewster, for example, noted that his attacks 'were never accompanied either with headache or gastric disturbance' while Airy, too, observed that 'in general, I feel no further inconvenience from it', although his friends found their attacks 'followed by oppressive head-ache'. These men were less interested in illness per se than they were in using their personal experiences to advance discussions about optics, vision and light that got to the heart of their beliefs about scientific authority, and indeed the very possibilities of seeing accurately and objectively with the naked eye. Elizabeth Green Musselman has written in detail about the ill health suffered by nineteenth-century men and women of science. She argues that they found meaning in nervous illnesses and failings such as hemiopsy, color blindness and hallucinations by applying their ideas about refined, well-managed, efficient nervous systems to science and society in general. While these discussions about ?half-blindness' contributed to contemporary scientific questions, their public airing also contributed to making these transitory visual attacks socially acceptable, even desirable. 

In a subsequent essay in the Philosophical Transactions of the Royal Society of London (1870), Hubert Airy, the physician son of the Astronomer Royal, drew together these accounts to propose that all of them (including himself) had experienced a phenomenon that he termed 'transient teichopsia'. Hubert did admit to suffering from terrible headache after the ?blindness', but did not consider that these visual phenomena were 'merely' a disease: such disorders would be 'hardly deserving of the attention of scientific men'. Rather, these functional disturbances should be regarded as 'a veritable "Photograph" of a morbid process going on in the brain', in which case, he thought, 'their interest and importance cannot be too strongly insisted upon'. Airy accompanied his paper with arguably some of the most beautiful imagery in the history of medicine: a series of sketches illustrating his own experiences of the disturbance across his visual field . With 'changing gleams' of red, blue, yellow, green and orange, at its height the vision 'seemed like a fortified town with bastions all round it'. The whole experience lasted half an hour. Despite the variety of words these men employed to discuss hemiopsy, it is important to emphasize that they made virtually no association between their discussions and any of the contemporary terms for migraine (including megrim, hemicrania, sick, nervous or bilious headache). A young Cambridge physician named Edward Liveing was in the audience for Airy's presentation of his paper to the Royal Society. He was impressed by Airy's careful observation and minute descriptions, as well as his 'excellent' drawings of the spectral appearances. For several years, Liveing had been collecting his own information and patient case notes about a group of ailments including sick, blind and bilious headaches, as well as hemicrania and hemiopsy (Liveing used the term 'hemiopia'). Liveing believed that these were all closely related. This was not an entirely new argument, but Liveing felt that English physicians needed to better understand these disorders as a family in order to catch up with the more comprehensive knowledge enjoyed by their French and German peers. Liveing brought these disorders under the umbrella term of megrim, which he explained was part of a larger family of functional disorders that included epilepsy, asthma and angina pectoris, all of which were characterized by paroxysms or fits. Liveing's book On Megrim, Sick Headache and Some Allied Disorders (1873) is now often considered to be a founding contribution to modern understandings of migraine in the English language. Memorably, Liveing proposed that attacks of megrim in all their manifestations were the result of an event in the body analogous to 'nerve-storm': a periodic dispersion of accumulated nervous energy. In the same year, another Cambridge physician, Peter W. Latham, published a second short book of two lectures On Nervous or Sick-Headache. In contrast to Liveing's nerve-storm theory, Latham explained the cause of migraine's visual aura as a contraction of the blood vessels of the brain, diminishing the blood supply and disturbing vision, followed by the vessels' ?dilatation' to bring on headache. Despite their theoretical differences, both books dedicated substantial space to reprinting the discussions that men of science had been having about visual disorders. In so doing, Liveing and Latham took migraine from the largely ignored realms of domestic recipe books, patent remedies and the classified pages of newspapers and infused it with a new authority, relevance and cachet through a firm connection with vision. These discussions were highly gendered and classed. 'Perhaps in a University town', Latham commented, 'it may be more prevalent among males than in other places'. Liveing also explained the disorder as a result of strained intellectual faculties, attacking over-worked students, 'literary men' or men who entered 'the more serious business of life'. Women were not exempt, but by contrast to men, Liveing's kind of megrim seemed to attack seamstresses or 'poor women exhausted from over-suckling'. Throughout the century, medical men had identified lower-class working women, their bodies and nerves broken down by exhaustion, overwork and poor diet, as the main sufferers of migrainous headaches, but megrim's emerging social visibility and acceptability in the late nineteenth century derived in large part from the central role that new theories about nerves gave to the personal testimony of scientific men, not to the experiences of seamstresses and nurses. In the remaining decades of the nineteenth century physicians from Britain and beyond continued to elaborate their own experiences of migraine in medical journals on both sides of the Atlantic. Sources:nih.gov; Wikipedia

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