Mrs. D.R., a 48 year-old, attractive French beauty operator, married, one 20-year-old daughter and one infant dead from breech complications, came in May 31st, 1949, with a long list of symptoms, mostly persistent headaches.
Her PAST HISTORY revealed the usual children’s diseases: whooping cough and a bad case of measles, frequent colds, bronchitis. Jaundice at the age of 23. Most of her difficulties started in 1935 when she was operated upon, in Algeria, for peritonitis followed by a severe loss of weight, gastroptosis and renal ptosis on the right side. Shortly afterward, she developed a lung abscess on the left and a purulent pleurisy on the right side that kept her 8 months in bed. About 3 years ago she suffered from an acute haemorrhagic nephritis and since that time, she has complained of hypertension, ringing in the ears with slowly progressive deafness, hot flashes, menstrual irregularities and loss of weight; all this, she said, as a consequence of the hardships endured in France during the war.
She has lived in San Francisco four years and has been crucified with chronic severe headaches ever since she came here. These headaches start every day between 4-5 a.m., lasting most of the day, often accompanied by nausea, retching and vomiting; they are located mostly over the right eye or in the occipital region, extending all over the head, somewhat ameliorated by her morning coffee, always worse at the end of the menstrual flow. Of course, all soon, she exhausted the list of pain killers only to find that she became “allergic” to them and had her stomach ruined by them. She cannot tolerate milk, cream, fats, chocolate and pastry. At times she gets so thirsty that she has to drink 10 glasses of water one after the other and again there are times
when she won’t drink a drop for days. Constipation has been most obstinate for years, her bowels don’t move “without something.” There have been no menses for 3 months, but before that she had all kinds of irregularities. Hot flashes persistently. She complains of frequent pains in the right upper quadrant (liver region) and under the right shoulder blade. Extremities are warm, so much so that she frequently sticks her feet out of the covers at night, and yet she is chilly and generally worse by cold and damp weather.
She perspires easily and freely. She has been a very poor sleeper for many years.
Since the headaches are the main complaint, let us consider some of the nosological of this syndrome. It is an accepted fact that migraine headaches and those produced by prolonged muscle contractions associated with anxiety and emotional tension are the most common types. Headaches due to septicemia rank next, to be followed by those due to nasal, paranasal and eye diseases.
Headaches produced by meningitis, aneurysm, brain tumor or abscess are much rarer. The outstanding features of the migraine syndrome are its periodicity, the unilateral onset that may become generalized, the associated nausea and vomiting, constipation or diarrhea, photophobia, scotomas and sensitivity to noises. Most of these features belong to our patient. However this type of headache is notoriously hereditary and we find no such evidence here.
In spite of considerable research and studies which have brought up many clever explanations as to the mechanism of migraine, and other types of headache, the cause is still unknown. Very similar to the migraine headaches are those associated with arterial hypertension. Both are known now to be produced essentially by the same mechanism. Both start in the early hours of the morning, as contrasted to other types of headaches starting during the day (nasal diseases) or evening (eye diseases, muscular contractions). Brain tumor headache has no connection with the time of day. If our patient’s headache can be tagged migraine, there is no doubt that hypertension is also an important factor.
Let us to her history. Her mental symptoms are worthwhile considering. She was in France during the war and suffered a great deal; in fact she has been “neurasthenic” ever since, she says. The depressive spells are more pronounced before menses. While in Algeria some years ago, She was attacked by an Arab and this brought a change in her usual sweet disposition, so that she often becomes angry and ill humored. As soon as settled anywhere, she wants to go away: may be she should go back to her native France, and yet she came to San Francisco thinking she would find happiness. She loves her husband dearly, but at times, she thinks she should divorce him.