MIGRAINE


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.

Affections of smell and taste are more unusual, but I had one patient who complained that everything, even coffee, tasted salt.

Mental excitement or mental depression may precede or accompany the seizures. One patient of mine was apt to feel unusually well the day before an attack.

The headache itself usually begins in a small spot or on one side and increases in force and extent until it affects all one side of head or even the whole head. In many cases it extends to the neck, shoulders and even arms. The pain itself is usually extreme, sharp, throbbing or boring, much worse for light, sounds, jar, or any decided motion. Rest in bed is absolutely necessary.

The pain often causes nausea and vomiting, which may take place repeatedly until bile is vomited. Many times the pain is relieved by vomiting and the patient falls asleep to wake feeling better.

Vasomotor symptoms such as pallor of the face, retraction of the eyes and contraction of the pupils accompany the headache. These may be succeeded by flushing of the face and the return of the pupil to its normal size.

While the above symptoms represent the ordinary case of migraine, each case is apt to show individual variations. Bartlett calls attention to the fact that other neurosis such as epilepsy or neuralgia may alternate with migraine in the same individual.

The attacks recur as a rule at intervals of two or four weeks and, in women, especially at the menstrual period. The duration is anywhere from five or six hours to three days.

The diagnosis of migraine should be very simple, for no other disease has the same combination of symptoms. However, occasionally migraine seizures occur in connection with organic cerebral affections, especially tumors, but here there should be symptoms pointing to a focal brain lesion.

Especially when the first seizure occurs in adult life, the possibility of an organic cause should be kept in mind, notwithstanding the fact that headache due to an organic condition is nearly always constant.

The prognosis made in a case of migraine must be guarded. Many cases recover on reaching middle life, and fortunately some recover under treatment.

Bartlett is of the opinion that continued aborting of the paroxysm lessens the frequency of the attacks and may finally lead to a cure.

The treatment of this disease may well tax all the skill and patience that the physician can bring to bear on the case. The diet should be carefully studied, because some patients are sensitive to certain foods and attacks follow their ingestion. Especially is this the case with protein foods.

On the other hand, care must be taken that the patient does not starve himself by refraining from too many foods.

A careful study should be made of the patients general condition, especially as to his eyes. His habits of work, rest and sleep must be ascertained and over-fatigue guarded against.

If the patient is excitable or irritable in nature, a certain amount of mental training may help to better poise and self- control.

Medicinal treatment is all too apt to take the form of palliation during an attack and the coal-tar derivatives are largely used for that purpose. Tight bandaging, hot or cold applications give relief to some patients. A study of such special peculiarities in each case may help to lead one to the right homoeopathic remedy, which to my mind is the only hope of a real cure.

A study of the constitutional symptoms should always be made in order that the remedy may fit the patient as a whole.

Sepia is often helpful in a patient of the type belonging to that remedy-sallow complexion, with tendency to dysmenorrhoea, and leucorrhoea, sensitive to cold. During an attack the patient desires warmth, darkness and absolute quite. Often the pain is helped by a tight bandage around the head.

Belladonna, Gelsemium, Calcarea, Ignatia, Spigelia, Nux vomica, Silica and Stannum are among the remedies to be thought of, but must be prescribed of course on the symptoms belonging to the individual remedy.

Sanguinaria often suits a right-sided headache, and Iris is another remedy for that side.

One of the difficulties in treating this, as well as any other disease, is to keep the patient from breaking in with a palliative in case of a hard attack. In fact it is often a great temptation to the physician to try to relieve an attack with some acute remedy, if the constitution remedy chosen has not yet acted sufficiently. Needless to say, this usually is a mistake.

Two cases which I have had lately show some of the complications which arise in our work.

I. Mrs. W.B. Age 45 years. Two daughters 19 and 13.

Twelve years ago had a fall fracturing the skull on the right side of the coronal suture. She now has headaches lasting several days. They usually begin in the night or early morning, and she wakens with the pain, which is expansive and very severe < stooping. Headache come at the menstrual period every other time.

For the last two years menstruation has been very painful every other time, with direction from front to back. Back very painful. Upper arms pain before menses.

Menses first at 11 years, painful at first with hard cramps. Since childbirth better, till lately.

In the last year and a half has had very great nervous strain owing to several cases of illness and one death in the family.

General physical condition good. Blood pressure 120/70.

Taking into consideration especially the injury from the fall, I gave on January 14, 1939, Hyper. perf. 1M. which was followed by some relief.

Two weeks later, January 28, I was called to see the patient, who was menstruating and suffering much pain in abdomen and back > firm pressure. There was also hard headache, extending down the neck > pressure.

For this I prescribed Nat. mur. 1M., but it did not relieve and twenty-four hours later I gave Nux vomica 1M. which relieved the condition.

Two weeks later there was another headache which began on waking, was worse in the occiput and extended to neck and back. There was the sensation of a tight band around the head, the eyes felt pulled back and there was aggravation from stooping. Sepia improved conditions promptly.

This remedy proved helpful for some time. A beginning headache was stopped by a dose of Sepia, and the menstrual condition was much relieved. For about three months the patient did not have a real headache.

In the autumn, after a busy summer, the headaches returned with menstruation and did not yield to Sepia. Besides the severe pain there were peculiar sensory phenomena. The hearing was abnormally acute, there were imaginary odors, and every thing tasted salt. Coffea 200 helped temporarily.

Then the pain returned with much chilliness and Silica 200 relieved. However, there was no sense of security and the patient was persuaded by a relative to see another physician, who ordered injections of theelin, an estrogenic hormone. I believe there has been an improvement in the condition of the head.

Case II. Mrs. E.M., dressmaker, English. Age 45. Three daughters, twenty-one, nineteen and sixteen. Divorced. In December, 1939, the gall-bladder was removed on account of severe headaches, vomiting and gastric pain. She made a good recovery from the operation, but the headaches persisted.

As a little girl she had “bilious” attacks and headaches, was a sickly child and had to be sent to the country to get stronger. There was some tuberculosis in the family.

At present the headache come every week or two. They begin at four or five a.m. and in the occiput, with a feeling that it is being crushed > turning on the abdomen. The pain then extends to the face, temples, zygomae and teeth; it begins on one side and goes to the other, > wet heat. The eye-sight is affected- everything looks angular. The pain causes nausea and vomiting, first of food, later of bile.

Four months ago during a headache she had a severe pain in the cardiac region with sweating and lost consciousness. Six weeks later she had an attack of clutching pain in chest with difficult breathing and much sweat. Since then occasional clutching pain in the epigastrium. Hospital examinations have failed to find evidence of coronary thrombosis, the diagnosis made at the time of attack, and an oculist who examined the eyes declared them “disgustingly healthy.” On Oct. 3, 1940, Mrs. M. came to me with the history given.

I found nothing organically wrong with the heart. Her blood pressure was 130/78. She complained of present dull pain in her left chest, a dull, heavy ache across the dorsal region > sitting straight, not > lying. Cact. gr. 1M.

The prescription was followed by improvement for six days. Then there was a slight pain in the chest with a sense of pressure as if she had swallowed something too large. Desires much air, cant have anything around the throat. Pulse rapid and irregular. She feels too large, and her hands feel swollen. Lach. 1M.

The next day she felt miserable. Her chest was sore, with pain in the cardiac region extending to the arms. On looking over the record I feel sure this was an aggravation after the Lachesis, but at the time I gave Cact, gr. 45M. which relieved, and the patient was comfortable for ten days.

Then at the half-way point between menstrual periods she developed a severe right-sided facial neuralgia which yielded to Spigelia 1M.

This remedy has been repeated a number of times for the excruciating neuralgic pain which came with, or in place of, the headaches.

On Feb. 15, 1941, the symptoms of aggravation at 4 p.m., oppression in the abdomen > for undressing, longing for open air, led to Lyc. 1M. and two months later the 10M. was given for aversion to descending stairs or a hill, depression and weeping, and troublesome dreams of the husband from whom she was divorced.

Later these dreams returned and were relieved by Sepia 200 and 1M.

On June 24, 1941, she declared herself better in many ways, especially mentally.

The summer was fairly good. The fall brought some return of symptoms and Sulphur seemed indicated and was given but without very marked benefit.

Later Psorinum seemed the remedy and apparently helped for a time. In February the menstrual flow, which had been more comfortable and normal, was very copious and lasted three weeks painless, bright liquid with large dark clots. It finally was > after Calcarea carb. 1M.

After the flow ceased I made a pelvic examination and found the uterus low and freely movable, but rather hard.

On March 4, I made a new study of the case, especially from the mental symptoms, as follows:.

1. Suicidal disposition. Keeps away from the river for fear of impulse to drown herself.

2. Discontented with her work, her home, etc. Not constant.

3. Desires light.

4. Aggravation from darkness.

5. Changing symptoms.

6. Changing pains.

7. Stitching pains in heels.

Pulsatilla has all the symptoms except the desire for light and ranked much higher than any other remedy. Its administration was marked by a short time of almost exaltation, so that the patient over-exerted herself sadly. However, the mental symptoms were relieved and when next she came to the office on April 6 a remedy stood out clearly. Sense of exhaustion in spring, < on waking, < heat; feels hot at night. Pain in chest < ascending. Heart feels big.

Lachesis 1M. brought a marked improvement, and at her last visit May 25 the patient declared herself very markedly better than a year ago.

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. NORTHAMPTON, MASS.

DISCUSSION.

DR. GREEN: Migraine is one of the hardest things to treat that we have to deal with, and perhaps nothing else needs such a thorough study of family background and chronic tendencies from way back.

I am inclined to think that the number of remedies indicated is not so large, and that the basic remedy which may be very discouraging at first, may yield the best results in the end. By a basic remedy I mean one that might have an acute complementary remedy that could be used as a palliative, without disturbing the action of the deeper one.

Dr. PULFORD: I want to call your attention to one remedy and the one condition in migraine, and that is skimmed milk. Lac defloratum has cured a number of cases of migraine for me by eliminating skimmed milk. The average milk of the city is skimmed milk, there is no doubt of it, and it is filled with artificial stuff, and then artificial cream that makes it look very rich. But I am positive that it is the base of a lot of these migraines.

DR. SUTHERLAND: The last case Dr. Stevens cited, I wonder whether a prescription of Cactus following Lachesis perhaps wasnt suppression and gave the difficulty encountered toward the latter end of the case. After she gave Pulsatilla, that unlocked that, and then Lachesis came back, which is now helping, I have lost the detail somewhat, but I recall there was Lachesis prescribed, with some amelioration, and then what appeared to be an aggravation from it. I think that was just the action of the Lachesis. Had the doctor waited a little while, that would have subsided and there would not be any occasion for the Cactus. Cactus is a suppressant.

DR. BRYANT: I just want to report one case which I think was cured under Niccolum, and to verify what Dr. Pulford had to say about Lac defloratum.

DR. STEVENS: I am sure Dr. Sutherland is right about my giving Cactus after Lachesis. It was practically at the beginning of the case, and I was scared, because the poor thing was suffering so much. But every time she has had some aggravation after the Lachesis. I am very sure this aggravation came the very next day after the first dose of Lachesis. If I had had my courage with me, and had given her plenty of Sac. lac., perhaps I would have gotten much more speedy results. She is still on Lachesis and improved, but she is really wretchedly tired, has had a very hard life. I think that rest is going to help very much, along with the remedy.

Grace Stevens