The prescribing in this case has been far from perfect, and there will undoubtedly still be some headaches; but there has been a gain both mental and physical and against heavy odds. Her life has been and still is exceedingly difficult, and she carries a heavy load of bad inheritance.

In offering this paper on migraine the writer makes not the slightest claim to originality. Even the cases presented do not show any brilliancy in prescribing-they are complicated and have been difficult to handle. Of the authors on this subject, Dr. Clarence Bartlett gives the most satisfactory analysis in his Practice of Medicine, and much of the description of the disease is quoted from that book.

Migraine, also called hemicrania, is a disease characterized by paroxysms of headache, generally associated with vasomotor and sensory symptoms. Bartlett calls it a disease of civilization and says that no neurosis numbers among its victims so many eminent scholars. It occurs more frequently in persons of neurotic constitution and about two-thirds of the sufferers are women.

Heredity has a strong influence in its production, either in a direct transmission of migraine from parent to child or more rarely in the neurotic manifestation taking the form of epilepsy or hysteria in the child. The disease usually begins in early life, often between the ages of five and ten years, the more marked the inheritance the earlier as a rule the beginning. After the age of thirty the liability to the disease is much lessened. People of gouty and rheumatic constitutions often suffer from the disease, and Haig makes the claim that the uric acid diathesis is the all-powerful causative factor. This conclusion Bartlett considers quite too sweeping.

Reflex irritation as caused by disorders of eyes, nose or teeth sometimes occasions attacks of headache but generally of less severe form than in migraine.

In true migraine the attacks, as a rule, occur spontaneously without any exciting cause, but often the victim learns that some special circumstance is apt to precede a paroxysm. Mental or severe bodily fatigue is many times an apparent cause; a railway journey, a day of shopping, or some depressing emotion has a bad influence. In many women the attacks occur at or about the time of the menstrual period and, in some cases, halfway between periods.

Very careful investigations have been made to find, if possible, some pathological foundation for the disease, but no structural changes have been found. I quote from Bartlett:.

Two theories have been advanced in explanation of the attacks. One offered by Gowers is that they are dependent upon periodical discharges of certain cortical cells in the brain, a “nerve storm.” This theory brings migraine into close relationship from a pathological standpoint with epilepsy. The other theory assigns a vasomotor origin to the disease. It provides that at the beginning of the attack there is a vasomotor spasm and this is followed shortly by vasomotor paralysis.

The angiospastic foundation for migraine appears to be confirmed by the association in the paroxysms of the numerous sensory and paralytic phenomena, which promptly disappear with the subsidence of the pain. A combination of the symptoms such as some cases display is unexplainable on any other than the hypothesis which provides for a spasm of blood vessels.

The fact that many of the attacks are associated with severe vomiting-often of bile-led in the past to theory that they were of gastric or hepatic origin, but that opinion is not longer held.

The attacks are usually preceded or ushered in by some sensory symptoms: a feeling of great fatigue, a heavy head, or something related to the special senses, most often to that of sight. These visual disturbances vary with the individual case, sometimes taking the form of one-sided dimness of vision, even progressing to temporary blindness; or again there is an appearance of fiery lines, making different forms, or saw-teeth of fire in rapid motion. This last form is characteristic of Natrum mur. One of my patients complained that everything looked angular and that she could not be sure of the exact position of objects.

Grace Stevens