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.

Grace Stevens