TheTREATMENTof these cases is that of chronic meningitis, with the added precautions against exposure to heat. In any severe case change of habitation to a cool climate during the hot period of the year is essential: twenty-four hours' exposure may undo all the good achieved by months of careful treatment.
It is hardly proper here to enter into a detailed discussion of the remedial measures to be employed in this as in the other forms of non-specific chronic meningitis. Local bleedings, the use of counter-irritation, especially by the actual cautery, the internal administration of mercurials and of iodide of potassium in small continued doses, with abstinence from brain-work and the regulation of the habits of life, constitute an array of measures which will no doubt be fully discussed by the author of the article upon Chronic Meningitis.
Provided the patient can be entirely controlled, thePROGNOSISin these cases is not so bad as at first it appears to be. As an instance of a remarkable recovery I condense from my notebook the case of T. W. H——, aged 49, who came under my care with a history that two years previously he had been seized during a hot day in the summer with a very violent headache, which continued for five weeks, confining him to bed, and was associated, as he said, with fever, but no other symptoms. This attack had been diagnosed by several physicians variously, but as I found that he was excessively affected by any exposure to the sun, was always worse in summer, and that in winter his symptoms were extremely exaggerated even by such heat in a room as is agreeable to many persons, I concluded that the original attack had really been one of thermic fever. He had lost about forty pounds in weight; his memory had become so bad for recent events that he could not call to mind things which had transpired one or two hours previously. Sight had failed much, and there was double vision. He suffered from almost incessant dull headache and excessive general wretchedness; the optic discs were slightly swollen, and one of the margins obscured. There was no albuminuria, and the dyspeptic symptoms were so bad that the man had been treated for months for dyspepsia. Nine months of treatment sufficed to restore this patient almost to his original health. The treatment consisted essentially in the alternate administration of minute doses of calomel and of iodide of potassium—in the meeting of various minor symptoms as they arose, but chiefly in the persistent, merciless use of counter-irritation at the nape of the neck. The actual cautery was applied every one or two weeks, and antimonial ointment freely used on the burnt surface.
BYWHARTON SINKLER, M.D.
BYWHARTON SINKLER, M.D.
SYNONYMS.—Cephalalgia, Cephalœa.
It is not possible to give in a few pages a complete treatise on headache, and it is therefore intended merely to describe the most common types of this malady.
Many forms of headache are symptomatic of some organic cerebral disease, like tumor of the brain or syphilitic diseases of the skull. Headache also constantly accompanies fevers of all kinds. A great number of cases are met with in which no cause for the headache can be discovered, and in which the pain is the only symptom. In these there must be some disordered state of the sensory nerves within the cranium, but just what the nature of the abnormal condition is it is impossible to decide.
The character of the pain in headaches is various. In some cases there is a violent general pain over the entire head. In others the pain is localized in one particular spot, feeling as if a nail were being driven into the skull. This is called clavus, and is often met with in hysterical patients.
Patients sometimes describe the head as feeling as if it were splitting open, or, again, as if it were being compressed. The pain may involve one side of the head alone, hemicrania, or it may be only in the back of the head. The top of the head is a frequent seat of pain, especially in women who have uterine disorders. In short, the pain may be in any or every portion of the head, or it may move about from place to place.
In almost all varieties of headache the pain is aggravated by noises or strong light. Any movements of the patient increase it, and coughing, sneezing, or straining—as, for instance, at stool—adds to the suffering. Tapping on the head usually does not increase the pain, and in some instances alleviates it.
Accompanying the headache is a variety of other symptoms: some of them are nervous, while others are not. There are often disturbances of vision, such as bright spots or zigzags before the eyes; and there may be ringing in the ears; palpitation or slowing of the heart. Nausea occurs in most varieties of headache, and a feeling of general prostration or nervous excitability is often experienced both during and after an attack.
The duration of an attack of headache varies from a few minutes todays or even months: one occasionally sees a patient who says she has not known what it is to have been without pain in the head for years.
The character of the pain may be either a dull aching or it may be excessively intense, so as to cause temporary aberration of mind. As to the structures within the cranium in which the pain is located, it is a mooted question. Some writers believe the dura mater may be the seat of pain in headaches, while other observers have declared this membrane to be insensitive. Probably the intracranial branches of the fifth pair of nerves are the principal site of pain.
We will now consider particularly the different varieties of headache most commonly met with.
ANÆMICHEADACHE.—The pain is of a dull kind, often diffused over the head, but frequently in the vertex or temples. It occurs in weak, thin-blooded persons, and is relieved by the recumbent position. If the patient is sitting or walking, the pain becomes worse, and there is a sense of faintness or dizziness. Women are the most common sufferers from this form of cephalalgia, and uterine diseases or disorders of menstruation are connected with it. It is associated with palpitations of the heart, difficulty of breathing, a tendency to faint, and general weakness. Anything which exhausts the nervous system, like over-study or anxiety, loss of rest and sleep, is likely to bring on an attack.
CONGESTIVE(HYPERÆMIC) HEADACHE.—In this variety of headache, which is common, the pain seems to affect the whole head and is of a dull, throbbing character. The recumbent position aggravates it, as does coughing or straining. During the paroxysm the face is flushed, the eyes suffused, and the arteries throb violently. Sleep relieves the pain of a hyperæmic headache for a time, but as soon as the patient begins to move about, or even to exercise the mind, the pain returns. Erb1speaks of a violent pain in the brow and temple, with a sense of pressure and fulness in the head, and heat and redness in the face and ears. This form may come in regular paroxysms. He has seen one case of this kind in which there was violent pain accompanied by fainting, and intense redness of the brow and vertex was observed.
1Cyclopædia of the Practice of Medicine(Ziemssen), vol. xiv. p. 140.
THEHEADACHE OFHYSTERIAis usually seen in females, although it may occur in males. It is sometimes general throughout the head, but is often located in one spot (clavus), and is very intense. The seat of clavus hystericus is at the top of the head to one side of the sagittal suture. The pain is described as boring, gnawing, and burning. The headache is more severe at the menstrual period, and is increased by worry or trivial excitement. Nervous and hysterical subjects complain of headache which never ceases.
TOXICHEADACHESare the result of the introduction into the system of various kinds of poisons. The headache following alcoholic excesses is a well-known instance of this kind. The pain, which is deep-seated and often intense, is supposed to be in the sensory nerves of the dura mater. Other forms of chronic poisoning give rise to headache. Lead, when retained in the system, produces headache, and so do many of the narcotic drugs. In some persons the administration of iron always causes pain in the head. The headache following a dose of opium is familiar to all. The excessive use of tobacco is often followed by dull headache nextday. The intense pain in the head caused by uræmic poisoning is a well-marked symptom of this condition. Seguin has lately well described the headache of uræmia.2
2Archives of Medicine, vol. iv. p. 102.
RHEUMATICHEADACHEis often violent, and the pain seems to be located in the head-muscles. It occurs in rheumatic subjects. It is brought on by exposure to cold, and is increased by damp changes in the weather. In acute rheumatism there are sometimes met with attacks of intense headache. Headache also is associated with the gouty cachexia, and is accompanied usually by depression of spirits and sometimes vertigo.
PYREXIALHEADACHES.—In all of the acute fevers headache is a prominent initial symptom, and usually continues throughout the course of the disease. The pain is generally dull and deep-seated, and is probably congestive in character. The headache of typhoid fever is constant, and often precedes the fever by many days. Following an attack of typhoid fever, it is not infrequent to find headache persisting for months or even for years.
SYPHILITICHEADACHEis one of the most violent forms of headache. The pain is diffused or limited to one part of the head, and is associated with tenderness of the scalp. It becomes most severe at night, but never entirely intermits. The nocturnal exacerbations, although very common, do not always occur. The pain is so violent and so constant that the patient is unable to do any work or to occupy himself in any way. There is great mental depression, and the patient becomes gloomy and morose. The pain may be dull and heavy or acute and lancinating; sometimes it is like a succession of heavy blows on the skull. During a severe paroxysm of pain the scalp becomes so sensitive that the lightest touch cannot be borne. The sufferer is unable to sleep, and presents a worn, haggard appearance. Often he has hallucinations at night. Syphilitic headache is often a forerunner of some form of organic cerebral disease. One of the characteristic features of syphilitic headache is its constancy. It never ceases entirely, although at times there are paroxysms in which the pain is so intense as to cause great agony. During the little sleep the patient is able to get he is moaning or tossing about his bed. Minute doses of mercury, repeated at short intervals, have been found to afford great relief in headaches of this kind.
ORGANICHEADACHEmay be described as the headache which accompanies organic disease of the brain or its membranes. Violent pain, seated in one spot and constant in character, is one of the most unvarying symptoms of tumors within the cranium. Brain tumors may exist without headache, but rarely. The pain may be situated in any part of the head: sometimes it is occipital and sometimes frontal, and occasionally it extends over the entire head. It does not always correspond to the seat of the disease. The pain is constant and lasting, and, like syphilitic headache, is liable to exacerbations of excessive violence. These often occur at night. Localized tenderness of the scalp is often present, and percussing the skull over the seat of the disease will increase the pain.
Disease of the membranes of the brain, such as meningitis or new growths in the dura mater, will give rise to persistent headache. So willcaries or any syphilitic affections of the skull. Catarrhal inflammation of the frontal sinuses causes dull frontal pain. In inflammatory diseases of the ear there is often headache. In these latter conditions the cephalalgia is probably reflex.
NEURASTHENICHEADACHEis more or less allied to the hysterical headache. It is met with in persons who are run down in their nervous system by mental worry or overwork—in other words, in persons who are suffering from neurasthenia. Such patients describe the pain as being constant and deep-seated—seldom acute, but dull and throbbing. It is accompanied by a sense of weight and pressure on the vertex, and sometimes by a feeling of constriction. Mental effort increases the pain, and the patient usually prefers solitude and quiet on account of the relief he obtains. The headache of neurasthenia often persists after other symptoms of the affection have disappeared.
SYMPATHETICHEADACHEis generally connected with disorders of the digestive and sexual organs. The headache of ovarian disease is well known to gynæcologists, and most of us have experienced the pain in the head associated with gastric disturbances. The headache from eye-strain may be considered in this connection, and deserves careful consideration. Many persons have suffered from headaches for years from this cause without its being suspected. Weir Mitchell brought prominently to notice the frequency with which headaches may be caused by defects of vision.3The fact had been long known to oculists that disorders of the refractive apparatus of the eye would give rise to cerebral discomfort and pain, but it had not before occurred to physicians to look to defects of the eye to explain headaches whose cause was obscure. The points made by Mitchell were—1, that many headaches are caused indirectly by defects of refraction or accommodation; 2, that in these instances the brain symptom is often the only prominent symptom of the eye trouble, so that there may be no ocular pain, but the strain of the eye-muscles is expressed solely in frontal or occipital headache; 3, that long-continued eye troubles may be the unsuspected cause of insomnia, vertigo, and nausea; 4, that in many cases the eye trouble becomes suddenly injurious, owing to break-down in the general health or to increased sensitiveness of the brain from mental or moral causes.
3Med. and Surg. Reporter, Aug. 1, 1874, andAmer. Journ. of the Med. Sci., April, 1876.
Occasionally the form of headache produced by eye-strain is a migraine, but most commonly there is a steady frontal or occipital pain, which comes on after undue use of the eyes, which are defective as to refraction or accommodation. Accompanying the pain are sometimes nausea and occasionally vertigo. It is not only over-use of astigmatic eyes in reading or other near work which causes the cerebral disorders, but the use of the eyes in the ordinary walks of life may produce pain in a sensitive brain should there be any imperfection in refraction or accommodation.
HEADACHE FROMSUNSTROKE.—A person who has had an attack of sunstroke often suffers from headache for years. The attacks are most likely to occur from exposure to the sun and in summer months, but they are brought on in some individuals even in winter should they be in the sun. Sometimes heat-exhaustion or exposure to the influence of the sun in hot weather, even should there be no actual sunstroke, isfollowed for a long time by violent headaches. Persons who have suffered in this way have to be extremely careful about exposing themselves to the sun or they will have severe and prostrating pains in the head. The cephalalgia in these cases is probably from congestion of the cerebral meninges or some disturbance of the submeningeal gray matter of the brain. The pain is usually frontal or on the top of the head. Sometimes it is confined to one side of the head. Mitchell4has seen two cases in which this form of headache was relieved by ligature of the temporal arteries.
4Med. and Surg. Reporter, July 25, 1874.
HEADACHE OFCHILDHOOD.—Children often suffer from headaches unconnected with meningitis or other organic brain trouble. Over-use of the brain in study is a frequent source of headache, in children especially, if associated with worry or anxiety. If a child complains of headache after study, it is always important to examine the eyes for defects of vision; but while this is often found to be the cause of the headache, in many cases there will be discovered no errors of refraction sufficient to account for the pain; and here the only relief will be to take the child from school and give him plenty of exercise and fresh air.
Another cause of headaches in children is hypertrophied tonsils, which prevent the free return of blood from the brain. Children also suffer from headaches from over-eating or improper food, or from over-exercise in the sun. Migraine, as will be seen later, is a disease which often begins in early childhood, and a child may suffer from frequent attacks of headache of this nature for a long time before they are understood.
Children who are precocious in any way are apt to be sufferers from neuralgias and headaches; but sexual precocity especially predisposes to headaches of the type of migraine. Anstie5goes so far as to say that the existence of a severe neuralgic affection in a young child, if it be not due to tubercle or to other organic brain disease, is, primâ facie, ground for suspecting precocious sexual irritation.
5Neuralgia and Diseases that Resemble it, p. 31.
Hillier6observes that anæmic children from seven to ten years of age frequently suffer from neuralgic headache, and that girls between eight and twelve have violent headaches accompanied by nausea and vomiting (migraine).
6Diseases of Children, p. 194.
HEADACHE FROMDYSPEPSIA.—Persons who have indigestion have more or less headache, either in paroxysms or as a constant pain. The pain is either frontal or occipital, and may affect the whole head; but it is not confined to one side of the head, as in migraine. The pain is usually dull, and is accompanied by nausea from the beginning of the attack. The tongue is coated, and has red edges, and there are general evidences of gastric disturbance, together with a history of some indiscretion in diet. Sleeping does not always relieve the headache.
DIAGNOSIS.—The diagnosis of the different forms of headache may be made by considering the symptoms. All of the means at our command should be used to carefully distinguish the variety of headache we have to deal with. The head should be palpated for tender or swollen and soft spots, such as are found often in syphilitic headaches. Sometimes percussion of the head will give us some indications as to the kind ofheadache which exists. The eyes should be examined ophthalmoscopically for changes in the fundus oculi, and the vision should be tested for errors of refraction should there be any reason to connect the pain with the use of the eyes. Inquiry into the habits, occupation, and family history of the patient will aid in arriving at a correct diagnosis.
TREATMENT.—Having reached a correct diagnosis, the treatment will naturally be directed to the special form of headache with which we have to deal. The indications vary more or less with the different varieties, but in all the same object is in view; that is, the relief of pain in the paroxysms, and the breaking up of the diseased condition which leads to the attacks. The means to be used for the former will be considered in the treatment of Migraine, and are more or less applicable to the treatment of all forms of headache.
In children, if no ocular cause is present, it will often be necessary to take them from school and study, and make them take plenty of exercise in the fresh air.
In all varieties of cephalalgia change of climate and travel exert a most beneficial influence. The seashore does not always benefit sufferers from headache, and sometimes the sea air seems to increase the pain.
SYNONYMS.—Hemicrania, Sick headache.
This form of headache is of great importance, from the frequency with which it is met in practice. It occurs in paroxysms at longer or shorter intervals, but the attacks come at periods of tolerable regularity, and, generally speaking, the intervals are entirely free from pain. From the name hemicrania it may be inferred that the pain is confined to one side of the head. This is often the case, but is not invariably the rule.
Migraine has been known for many years, and the term hemicrania is used by the old writers. Until recently, however, there has been some confusion regarding it. Hemicrania often meant trigeminal neuralgia, and nervous sick headache was generally believed to have its origin in the stomach or to be the result of biliousness. Of late years the disease has come to be better understood, and the valuable works of Liveing, Anstie, and others have given a full literature of the subject.
Various conditions predispose to migraine, and of these the foremost are period of life and hereditary influence. Sex also bears a part in the etiology. The majority of patients who are victims of migraine are females. Eulenburg7states that the proportion is about 5 to 1 in favor of females. My own experience would lead me to believe that in this country the preponderance of migraine in females is not so great. Men are not so likely to consult a physician about headaches, unless they become very frequent and severe; especially is this true of the laboring classes, from whom Eulenburg's statistics were mainly taken. It is true that women are especially prone to neuroses of various kinds through menstrual disorders and at the time of the climacteric, but these do not always take the form of migraine.
7Ziemssen's Cyclopædia, vol. xiv. p. 5.
Age has a decided influence on the production of migraine. Sometimesthe attacks begin in very young children. Eulenburg mentions cases at four or five years. It is during the period of bodily development that the first outbreaks of migraine occur, but more particularly do they set in in both sexes at puberty, a time when sexual development is active and making a strong impression on the whole nervous system. Should migraine become established at this time, it will probably continue to harass the individual until he is forty-five or fifty years of age. After the development of puberty migraine is not likely to originate; indeed, Tissot8declares that a person who is not attacked by migraine before his twenty-fifth year will escape from it for the rest of his life. It certainly is the case that in later life this affection is much more rare than earlier, as many of the old cases get well and new ones scarcely ever develop. It is a common thing to hear a patient who has reached the age of fifty extolling some new system or remedy as a cure for his headaches, from which he has suffered all his life, when in reality the attacks have ceased or become infrequent on account of the natural course of the disease.
8Quoted by Eulenburg,op. cit.
Hereditation markedly affects the production of migraine. Eulenburg states that it follows the female line, and is inherited from the mother only; but this is surely a mistake, as we often see males whose fathers suffered from migraine. Persons whose ancestors were of a neurotic type, who suffered from neuralgias, paralysis, hysteria, insanity, etc., are particularly liable to migraine. Epilepsy is also likely to be in the family of an individual who has migraine. There has been observed by many writers the association of migraine and epilepsy in the same person. Epileptics who are predisposed to the disease by inheritance are likely to have attacks of it preceding the outbreak of epilepsy. In families of constitutional nervous tendencies it is common to see certain members who have hemicrania, while others have epilepsy or are insane.
Other predisposing causes in migraine are not so marked as those already mentioned. Station in life exerts but little influence in the causation of the disease. It is met with as often in the laboring classes as in the wealthy. Those who use the brain to any extent in study or business are likely to suffer more often from migraine than those who lead an outdoor life with much physical exercise. Habitual loss of sleep and anxiety also predispose to it.
As to the conditions connected with the immediate production of an attack of migraine, we are in ignorance. It has been thought to depend upon disorders in the circulation of the blood, but then the question arises, Whence these disturbances of circulation? Probably those circulatory disorders which are marked in every case are effect rather than cause of the attack. Indigestion and biliousness must be admitted to favor outbreaks of migraine.
SYMPTOMS.—Migraine occurs at intervals of one or two weeks or longer; often the attacks are not more frequent than every month or even two or three months. I have seen a number of patients who have attacks of migraine on Sunday with regularity, and escape during the interval. Some of these cases ascribed the attacks to sleeping later on this day than on others, but it is more likely that the attacks were the result of the culminating effect of a week's hard work. Between the attacks the patient is usually quite well as far as headache is concerned,but he may have slight neuralgia in branches of the trigeminal. The attacks are more or less alike. They are often preceded by prodromal symptoms for a day or two. The patient may feel languid or tired for a day before the attack. Sometimes there is unusual hunger the night before a paroxysm, or there may be violent gastralgia before each attack. The patient often wakes in the morning after sound sleep with a pain in the head. Should the attack come on in the day, it may be preceded by chilliness, yawning, or sneezing and a sense of general malaise. Ocular symptoms are frequent as a forerunner of an attack. First muscæ volitantes are seen, then balls of fire or bright zigzags appear before the eyes, making it impossible for the patient to read. These symptoms last for a few minutes or a half hour, and then cease, to be immediately followed by pain. Hemianopsia is a precursory symptom of rather frequent occurrence. Ross mentions a case in which the hemianopsia usually lasted about a half hour, and was followed by severe hemicrania. The ocular symptoms are often very alarming to patients.
The pain, as a general rule, is at first in the ophthalmic division of the fifth nerve and its branches. It may begin in the branches of the occipital nerve or in the parietal region. It comes on gradually, is dull and boring at first, but becomes more intense and spreads to one lateral half of the head, more especially the front part. As it increases in intensity the pain seems to involve the entire head. Either side of the head may be affected. Eulenburg thinks that the left side is attacked twice as often as the right. An individual may have the pain on opposite sides of the head alternately in different attacks. The pain is described by patients as dull and boring or intense, and the head feeling as if it would burst. Patients often make pressure on the head to obtain relief. At times the pain seems to be of a violent, throbbing kind, keeping time, as it were, with the pulsation of the arteries. Lying down usually relieves the pain, but if it is violent the recumbent position seems to favor the afflux of blood to the head, and thereby increases the pain. The eye of the affected side becomes bloodshot, and the tears stream from it. The eyelid droops, and the sight is dim and clouded or may fail entirely. The least light is unbearable. During the attack the subject is chilly and intensely depressed, and the feet are very cold. The pulse is at first slow, small, and compressible.
Painful points (Valleix's points) are not present, but there is usually tenderness over the supraorbital notch during an attack of migraine, and after the paroxysm there is a general soreness of the scalp and forehead. Sometimes there remains a tenderness of the parts surrounding the affected nerve. This is not in the nerve itself, but in the adjacent tissues. Anstie9says that in his own case, after repeated attacks of migraine, the bone had become sensibly thickened in the neighborhood of the supraorbital notch. There is sometimes hyperæsthesia of the skin in the affected regions of the forehead and scalp during an attack. As well as hyperæsthesia, there may be an abnormal acuteness of the sense of touch. Deep pressure over the superior and middle ganglia of the sympathetic causes pain, according to Eulenburg. This observer also states that the spinal processes of the lower cervical and upper dorsal vertebræ are painful on pressure.
9Op. cit., p. 182.
During the attack of migraine there is complete loss of appetite, and any food that may be taken remains undigested in the stomach for hours. As the pain intensifies there comes on a sense of nausea, there is a profuse flow of saliva, and large quantities of limpid urine are passed. Finally, when the pain seems to have reached its maximum, vomiting occurs. Immediately afterward the pain is greatly increased, but this is the result of the increased amount of blood in the cranial cavity from straining. Soon after, the patient is easier, and falls into a sleep, from which he awakes free from headache. The crisis is not always accompanied by vomiting. In some instances there is no nausea, but at the acme of the pain there are two or three profuse diarrhœic stools, after which the pain is relieved. I have lately seen such a case in a young man of twenty-three years of age. Sometimes there is only a profuse sweat or large flow of urine.
During the attack there are disorders of the circulation. The pulse may be intermittent or irregular, and the extremities are usually cold. Disorders of cutaneous sensibility are also often present. A condition of numbness confined to one lateral half of the body is sometimes experienced during the early part of the paroxysm. This numbness is noticed even in one half of the tongue.
The German writers have divided migraine into two types, and the arrangement may be followed in some instances. The first is called hemicrania spastica or sympathico-tonica. In this form there is supposed to be vascular spasm and a diminished supply of blood in the brain. The symptoms are as follows: When the attack has reached its height the face is pale and sunken; the eye is hollow and the pupil dilated; the arteries are tense and feel like a cord. The external ear and the tip of the nose are cold. Eulenburg10states that by actual measurement he has found the temperature in the external auditory meatus fall 0.4° to 0.6° C. The pain is increased by stooping, straining, or anything which adds to the blood-supply in the head. At the end of the attack the face becomes flushed and there is a sense of heat. The conjunctiva becomes reddened, the eye is suffused, and the pupil, which had been dilated, contracts. The sense of warmth becomes general, the pulse is quickened, and the heart palpitates. The crisis is reached with vomiting and a copious flow of urine or perhaps a diarrhœic stool. There is sometimes an abundant flow of saliva. One observer has reported that he has estimated a flow of two pounds of saliva during an attack.
10Op. cit.
The other variety is termed hemicrania angio-paralytica or neuro-paralytica. Here we find the opposite condition of things from that met with in hemicrania spastica. There is marked increase in the amount of blood in the brain. When the attack is at its height the face on the affected side is flushed deeply, hot, and turgid. The conjunctiva is injected, the lachrymal secretion increased, and the pupil contracted. Sometimes there is slight ptosis. The ear on the affected side is hot and red. The temperature of the meatus may rise 0.2° to 0.4° C. The temporal artery is swollen, and throbs with increased force. The carotid beats visibly. There is free perspiration, which is sometimes unilateral. Compression of the carotid on the painful side relieves the pain, while pressing on the opposite carotid makes it worse. The heart beatsslowly, the pulse being sometimes as low as 48 to 56. At the end of the attack the face becomes paler and the other symptoms subside.
There are many cases in which the vascular conditions present no peculiarities during the attack, and which cannot be classed with either of the varieties just described.
In all forms, if the patient can be quiet, he usually falls asleep after the crisis has been reached, and awakes free from pain, but feeling haggard and prostrated.
The paroxysm lasts for several hours, generally the greater part of the day. It may last for several days, with variations of severity. The attacks are at longer or shorter intervals of time, and in women they often appear at the menstrual period. The attack may be brought on by over-mental or bodily exertion, imprudence in eating or drinking, and exposure to cold draughts of air. It will often begin as a supraorbital neuralgia from exposure to cold, and go on through all the phenomena of a regular migraine.
Seizures are often brought on by fatigue, and there are some persons who invariably have a violent attack of migraine after a journey. Nursing women are liable to more frequent paroxysms, and I have recently seen a lady who within a few days after delivery after both of her confinements suffered from typical attacks of migraine, although during gestation she had escaped them.
DIAGNOSIS.—Migraine can readily be distinguished from the other forms of headache by the comparative regularity of the attacks and its numerous other characteristics. It differs from neuralgia in the pain being less acute and shooting. The pain of migraine is more dull and throbbing, and extends more generally over the head. The ocular phenomena are more or less constant in migraine and do not occur in neuralgia.
PROGNOSIS.—Migraine is never fatal, and usually becomes less severe and less frequent as middle life is reached. Some patients continue to suffer from it during their entire life, and often when the typical migraine has ceased it is replaced with paroxysms of neuralgia. Therapeutic and hygienic means are of decided influence in the course of the disorder, and many patients experience great relief or temporary immunity from attacks as a result of treatment. Cases of long standing and those of an hereditary type are most unfavorable as to relief from treatment or by spontaneous cure.
PATHOLOGY ANDMORBIDANATOMY.—Migraine not being a fatal disease, we know nothing of the changes which exist in the brain; we can only surmise what are the conditions which exist in the brain during and before an attack.
It is evident that there is a strong relationship between migraine and neuralgia of the trigeminal nerve, and if we study the symptoms of the two conditions, and consider the causes which produce attacks of each, we cannot but arrive at the conclusion that migraine is a variety of a neuralgia of the ophthalmic division of the fifth. The late Anstie has most clearly and forcibly given his reasons for believing this to be the case, and we cannot but uphold his view.
Migraine is constantly met with in early life as the type of a neuralgia which in later years loses the special features of a sick headache and becomesa pure neuralgia. The same forms of trophic lesions may occur in migraine and in trigeminal neuralgia. Anstie instances his own case, in which in early life he had distinct attacks of migraine, with corneal ulceration, orbital periostitis, and obstruction of the nasal duct, while later in life his attacks were only neuralgic, without any stomach complications.
Migraine, as already remarked, attacks early life especially at the time of sexual development, and the same is true of epilepsy. There is also the same hereditary predisposition to the former as to the latter. Patients who have migraine belong often to families other members of which suffer from epilepsy, chorea, and an uncontrollable tendency to alcoholic excesses. Indeed, occasionally migraine and epilepsy are interchangeable in the same individual. Many cases of epilepsy have suffered at some time of their lives from severe headaches.
Hughlings-Jackson describes the attacks of migraine as arising from a discharging lesion of the cortex of the brain in the sensory area, or in that part of it which corresponds to the region of pain in the head. Genuine epilepsy he holds to be due to a discharging lesion from the motor area of the cortex. During an attack of migraine the discharging lesion does not remain confined in the sensory portion of the cortex, but extends into the medulla oblongata and the cilio-spinal region of the cord, causing irritation or paralysis of some of these centres, and causing the vaso-motor and oculo-pupillary symptoms which are conspicuous during an attack.
In the form of migraine known as hemicrania sympathico-tonica there is tonic spasm of the vessels of one side of the head. This explains the pallid face, the lowered temperature, and the sunken eyes. After the cause of the contraction is removed, then the vessels relax and the amount of blood-supply greatly increases. Hence the redness of the conjunctiva, lachrymation, and redness of the ear at the close of an attack. The vomiting is explained by Eulenburg as being due to variations in the intracranial blood-pressure. This causes fitful contractions of the vascular muscles, alternating with partial relaxation. These conditions must arise in the sympathetic nerve of the corresponding side.
The dilation of the pupil during an attack depends upon irritation of the cervical sympathetic ganglia. Other symptoms, such as the largely increased flow of saliva and the flow of tears or drying of the Schneiderian mucous membrane, indicate a morbid condition of the cervical sympathetic. The sensitiveness to pressure in the region of the upper cervical ganglia and over the spinous processes of the lower cervical and upper dorsal vertebræ, corresponding to the cilio-spinal region of the cord, confirms the idea of a morbid state of the cervical sympathetic.
In hemicrania angio-paralytica there is supposed to be a relaxed condition of the vessels of one side of the head. Here, instead of an irritation of the sympathetic, there is a paralytic condition, and we have the same results as are seen in animals when the cervical sympathetic is divided. There seem to be good grounds for holding this view when we consider the flushed face, contracted pupil, retraction of the eyeball, and occasional ptosis which accompany this form of headache. Possibly there may be a brief stage of spasm of the vessels preceding the relaxation which occurs in hemicrania angio-paralytica.
The slowing of the pulse during an attack of migraine is due probably to cerebral hyperæmia from relaxation of the vessels, or to the secondary anæmia and irritation of the medulla oblongata. This irritation of the medulla is also able to explain the other symptoms of vaso-motor disturbance which occur during an attack of migraine; for instance, the small and contracted radial artery, the extreme coldness of the hands and feet, and the suppression of perspiration over the whole body except perhaps on the affected side of the head. Following the stage of irritation of the medulla with contraction of the vessels comes one of exhaustion with relaxation of the vessels. This latter state may account for the profuse flow of saliva and the copious secretion of sweat and urine, as well as the increased secretion of bile and the condition of broncho-tracheal catarrh during the attack.
We now come to the question of the origin and seat of the pain in migraine. This question has involved a great deal of thought, and has been answered in various ways by different writers. E. du Bois-Raymond thought that the pain was due to tonic spasm of the muscular coats of the vessels, and that thereby the nerves in the sheaths of the vessels were pinched, as it were, and so caused pain. Moellendorff was of the opinion that the pain was due to dilatation of the vessels, and not to contraction; and this theory might explain the pain in the angio-paralytic form. There are many cases in which neither of these views is sufficient, for we have no reason to believe that a condition of either anæmia or hyperæmia is present.
Romberg believed that the pain was situated in the brain itself, and Eulenburg holds that the pain must be caused by alterations in the blood-supply, without regard to their origin, in the vessels of one side of the head. He thinks that the vessels may contract and dilate with suddenness, just as is often seen in some neuralgias, and thus intensely excite the nerves of sensation which accompany the vessels. The increase of pain upon stooping, straining, or coughing, and the influence upon it by compression of the carotids, seem to give force to this view. But are we not here confusing cause with effect? Are not these variations in the calibre of the vessels due to the irritation of the sensory and vaso-motor nerves, which are in a state of pain? No doubt increase in the blood-supply augments the pain, just as it does in an inflamed part when more blood goes to the part. Let a finger with felon hang down, or let a gouty foot rest upon the floor, what an intensity of pain follows!
Anstie very ably advocated the theory of migraine being a variety of trigeminal neuralgia in the ophthalmic division; and we incline strongly to his view. An attack of migraine often begins with pain distinctly located in the supraorbital nerve as the result of exposure to cold. Frequently it begins in the infraorbital nerve or in the branches of the inferior maxillary division of the fifth. The pain then spreads over one side of the head, both outside and inside, and goes through the recognized symptoms of migraine. In my own case I have often had an attack begin with sharp pain in the supraorbital notch in a spot which could be covered by the tip of the finger. The nerve has seemed swollen, and has been highly sensitive to pressure. Then have come pain extending over the entire side of the head, without its limits being distinctly definable, and the accompanying phenomena of lachrymation, excessive salivation,and copious flow of urine, winding up with vomiting or ineffectual nausea and retching.
Anstie brings forward as arguments to support his view the facts that the attacks of migraine often interchange with neuralgic seizures, and that a person who has been migraineuse in early life may in later years lose his hemicranial attacks, and have violent neuralgia in the ophthalmic division of the fifth nerve.
The true seat of the lesion, if we may so call it, upon which the exaggeration of pain-sense depends, is probably in the nerve-centre; that is, in that part of the trigeminal nucleus back to which the fibres go which are distributed to the painful areas. The pain is no doubt chiefly intracranial, and in those portions of the cerebral mass and meninges to which branches of the trigeminal are distributed. All of the divisions of the trigeminus send branches to the dura mater. Many nerves are found in the pia mater as plexuses around the vessels, some of which penetrate into the centre of the brain. Most of these nerves come from branches of the trigeminus.
TREATMENT.—The treatment of migraine must be directed to the palliation of the attacks and to their prevention. So little is known of the direct cause of the disease that it is difficult to lay out any distinct course to be followed. Many cases, however, which seem to depend upon a run-down state of the patient are vastly improved by a course of tonics and building up. I have often seen anæmic and feeble women whose attacks were frequent become exempt for a long period by simply taking iron, quinine, and strychnia, and taking an increased amount of nourishment. The rest-treatment of Weir Mitchell is particularly applicable to these cases. In persons whose digestion is bad, and who suffer from constipation, much can be done by relieving these conditions. Some cases which are due to uterine disturbances are benefited by treatment directed to the womb. There are many cases, however, in which no cause is apparent. The patient is well nourished, his eyes are good, he undergoes no strain mentally, morally, or physically, and yet the attacks of migraine come with tolerable regularity. In these persons change of climate sometimes works marvellously beneficial results. I saw last year a young lady who suffered from terrific headaches which sometimes lasted for days. No plan of treatment or regimen seemed to exert the slightest influence upon the attacks, and yet on going to the far West for the summer she remained without an attack during the whole time she was there. In some individuals all forms of treatment may be tried in vain. Anti-periodics have been tested, but with doubtful benefit. Cannabis indica is probably the most potent remedy which is at our command. Its effects are most decided, and many cases of severe hemicrania have been cured by this means alone. It must be given for a long time, and in some instances it is necessary to give gradually-increasing doses up to the physiological effects. The drug must be of good quality, otherwise we need expect no good from it. Indian hemp is well known to be variable in strength, and the best form in which to use it is a fluid extract made by some reliable chemist. Arsenic, phosphorus, and strychnia do not seem to do as much good as in other neuralgias, except so far as they build up the general health.
Ergot has been used with success as a curative means, and it probablyacts by contracting the vessels of the medulla oblongata. A combination of ergotin and extract of cannabis indica may be given together; and if persisted in for a long time will often be of benefit in lessening the frequency of the attacks. The prolonged use of one of the bromides is sometimes found curative.
Anstie has found the careful use of galvanism to the head and sympathetic of positive advantage in keeping off attacks, and Eulenburg has had the same experience.
In the treatment of the attack the patient should be freed from all sources of external irritation. He should lie down in a darkened room, and all noises should be excluded. If the attack is of the hyperæmic variety, the patient's head should not be low, as this must favor increase of blood to the head. In this form the patient is often more comfortable sitting up or walking about. Occasionally an impending attack can be warded off by the administration of caffeine, guarana, or cannabis indica. Purgatives are of but little value in this form of headache. The local application of menthol or of the oleate of aconitia to the brow of the affected side will sometimes prevent an attack. If a person can lie down quietly when he feels an attack coming on, one or two doses of fifteen grains each of the bromide of lithium will enable him to sleep, and wake free from pain. I have found the lithium bromide far more valuable in migraine than any other of the bromides. An effervescing preparation known as bromo-caffeine is often efficacious in aborting a paroxysm or in palliating it when it has got under way.
Quinine, in my experience, seems to be of little use in preventing or cutting short a paroxysm of migraine, although Ross11has found that a dose of ten or fifteen grains may arrest it. Ergot has been found useful, and, as it acts by contracting the arterioles, should be given only in the angio-paralytic form. The fluid extract of ergot may be administered, but ergotin in pill form is more acceptable to the stomach.
11Diseases of the Nervous System, vol. ii. p. 558.
Inhalations of nitrate of amyl have been used with advantage. Berger, who was the first to employ this remedy, found that a single inhalation of a few drops relieved the pain at once, and it did not return that day. It is indicated only in the sympathico-tonica type. If it is used, two or three drops of the nitrate in a glass pearl may be crushed in the handkerchief and inhaled. Nitro-glycerin may also be given in this variety of migraine.
Once the attack has begun fully, we can only attempt to mitigate the pain. Firm pressure on the head generally gives relief, and encircling the head firmly with a rubber bandage is often of great comfort. Compression of the carotids gives temporary but decided ease to the pain. Strong counter-irritation in the shape of a mustard plaster to the nape of the neck or a stimulating application, like Granville's lotion, to the vertex, will afford relief. I have found in some cases that placing a hot-water bag, as hot as could be borne, against the back of the head alleviates the pain. In other instances cold affords more relief, and an ice-bag resting upon the forehead is the most efficacious way of applying cold. Hot bottles to the feet are an accessory not to be overlooked.
In the way of medicine we may give the bromide of lithium every hour. The bromide of nickel has been recommended by DaCosta ashaving peculiar advantages. Cannabis indica may be given in doses of a quarter of a grain of the extract every two hours until relief is obtained. Anstie believes strongly in chloral, and says that a single dose of twenty or thirty grains will often induce a sleep from which the patient wakes free from pain. The same writer advises the administration of muriate of ammonium, but it is too nauseous a dose to be given when the stomach is as much disturbed as it usually is in an attack of migraine.
Croton chloral is preferred by some to the chloral hydrate. Ross, for example, gives it in doses of five grains every four hours until relief is obtained.
Galvanism through the head is often of relief, especially at the beginning of an attack; but this means is not often available, for it is not easy to have the suitable apparatus for the constant current at a patient's home when it is needed. Should galvanism be used, one pole should be placed on each mastoid process, and a weak current passed through the head for two or three minutes. The sympathetic may be galvanized by placing one pole over the upper cervical ganglion, just behind and below the angle of the jaw, while the other pole is held in the hand or placed upon the sole of the foot. In hemicrania spastica the positive pole is put over the ganglion, and in the angio-paralytic type the negative pole is placed in this location.
Should all of the above means fail, we may resort to morphia hypodermically. Jewell12favors the administration of morphia and atropia, either by the mouth or hypodermically, from the beginning of an attack until the pain is eased; but I believe that morphia, except as a last resort, is very undesirable in migraine. Although a small dose hypodermically will usually promptly bring relief, there are the unpleasant after-effects of opium felt, and the patient feels more prostrated and with more disordered digestion than had no morphia been used. Besides, the morphia habit is liable to be formed, especially in women, when the drug has once begun to be taken.
12Journal of Nervous and Mental Diseases, 1881.
It is for this reason that I prefer to use the bromides, and if a patient is seen at the beginning of a paroxysm, given a fifteen-grain dose of bromide of lithium, his feet put in hot mustard-water, and he then goes to bed, he will almost always cut his attack short, and on waking from sleep will feel refreshed and able to take food.
I am strongly convinced of the importance of arresting or shortening the paroxysms of migraine, especially in the young, at the beginning of the disease. By this means the habit of long attacks is prevented, and their prostrating after-effects are avoided. Should we succeed in checking the first few attacks, we may by tonics and regimen improve and fortify the constitution so as to eradicate or modify the neuralgic tendency.