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Continuing Education for Health Professionals

Migraine Headaches

Module 1

A Brief History of Migraine

My head doth ake
O Sappho! Take
Thy fillit,
And bind the paine;
Or bring some bane
To kill it.

Robert Herrick (15911674)
The Head-ake

Historically, migraines have been treated based on the limited medical understanding of the time, or with procedures rooted in superstition or witchcraft. Skulls from 9,000 years ago show evidence of trepanationthe deliberate and (usually!) nonfatal drilling of holes into a skull to allow the evil spirits to escape. It is thought that this drastic step was taken in response to headaches, based on cave paintings and on the fact that trepanation was a migraine treatment much more recently, in seventeenth-century Europe.

Headache with neuralgia was recorded in the medical documents of the ancient Egyptians as early as 1200 B.C.E. Noting descriptions of the clinical and medical symptoms in earliest writings, it appears that migraines are among the oldest diseases known to mankind (Migraine history, 2011, news-medical.net).

Hippocrates described, in 400 B.C.E., the visual aura that can precede the migraine headache and the relief that can occur after vomiting “to release the bad vapors.” Aretaeus of Cappadocia is credited as the discoverer of migraines because in the second century he described symptoms of a unilateral headache associated with vomiting and the headache-free intervals between attacks.

Hua T’o was a Chinese surgeon during the late Han Dynasty (second century A.D.) and was the first in China to use anesthetics during surgery. He may also have been the first to use acupuncture needles successfully to cure the recurrent migraines of the tyrannical founder of the kingdom.

Galenus of Pergamon used the term “hemicrania” (half-head), from which the word “migraine” was derived. He thought there was a connection between the stomach and the brain because of the nausea and vomiting that often accompanied an attack.

Demonic Depiction of Headache in 1819

image: Cruikshank print

Work of art by George Cruikshank (17921878). Source: Wikimedia Commons.

In the Middle Ages, migraine was recognized as a discrete medical disorder with treatment ranging from hot irons, to blood letting, to insertion of garlic into an incision made into the templeand even to witchcraft. Others would apply opium and vinegar solutions to the skull for “directed” pain relief.

Persian-born Abu Bakr Mohamed Ibn Zakariya Râzi (865925; Latinized name, Rhazes) noted the association of headache with what, in the lives of women, are now identified as hormone fluctuations: “And such a headache may be observed after delivery. . . or during menopause and dysmenorrhea.”

One of the most celebrated philosopher-scientists of Islam, Ibn Sina (9731037; Latinized name, Avicenna), described migraine symptoms in his textbook On Medicine: “. . . Small movements, drinking and eating, and sounds provoke the pain. . . The patient cannot tolerate the sound of speaking and light. He would like to rest in darkness alone.”

In Bibliotheca Anatomica, Medic, Chirurgica, published in London in 1712, five major types of headaches are described, including the “megrim,” recognized today as classic migraine with preceding aura (Migraine history, 2011, news-medical.net).

In the modern era, Graham and Wolff (1938) published a paper advocating ergotamine tart to relieve migraines. This was perhaps the first true medication, as it actually gave relief by causing vasoconstriction in the brain’s blood vessels, which had been dilated in migraine. Side effects included nausea, vomiting, and sometimes drug dependence. Later, Wolff developed the experimental approach to the study of headache and elaborated the vascular theory of migraine, which is only now being superseded by a genetic, neurogenic model of migraine.

The newer ergot drug in the 1950s, dihydroergotamine (DHE), also acts nonspecifically on all serotonin receptor subtypes leading to vasoconstriction, though with gastrointestinal and other migraine side effects unaddressed.

The 1990s saw development of the triptans such as Imitrex (sumatriptan) for acute treatment of migraine attacks. It is a selective agonist specifically targeted for the serotonin 5-HT1 receptor, constricting the dilated blood vessels and relaxing the pain and associated symptoms with fewer off-target side effects.

The Herbal Remedy, Feverfew

image: feverview

Tanacetum partheniumcommon name, feverfew. Source: Wikimedia Commons.

Through the centuries, many herbal remedies have been used to treat migraine headaches. The butterbur family of plants and the feverfew plant (right) have been used historically for headache relief (see Module 8 on alternative medicines). Study results have indicated that feverfew and butterbur may help reduce migraine frequency, though side effects can be serious, so quality of the herbal source is important.

Some of notable migraine sufferers include Thomas Jefferson, John F. Kennedy, Julius Caesar, Napoleon Bonaparte, Charles Darwin, Albert Einstein, Cervantes, Sigmund Freud, Elvis Presley, Elizabeth Taylor, Ulysses S. Grant, Robert E. Lee, Lewis Carroll, and Vincent Van Gogh, who painted aura-like forms in some of his works.

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