As early as 7000 BC, signs of ancient neurosurgery were evident. Neolithic skulls show that trepanation (the removal of a segment of bone from the skull) was widely performed. Trepanation may have been performed to release demons and evil spirits from the head. Ancient man believed these spirits were the cause of headaches and disorders such as madness and epilepsy. Trepanning was still recommended by some 17th century physicians for the treatment of migraine. In 1660, William Harvey recommended trepanation to a patient with intractable migraine.
The Ebers Papyrus, dating back to about 1200BC and named after a professor of Egyptology, mentions migraine, neuralgia, and shooting head pains, and is said to be based on earlier medical documents from around 1550BC. Following the instructions on the papyrus, the Egyptians would firmly bind a clay crocodile holding grain in its mouth to the head of the patient using a strip of linen. The linen bore the names of the gods whom the Egyptians believed could cure their ailments. In actual fact, the process may have relieved the headache by compressing the scalp, and possibly collapsing distended vessels that were causing the pain.
Hippocrates – in 400 BC – was the first to describe visual symptoms of migraine. He described a shining light, usually in the right eye, followed by violent pain beginning in the temples and eventually reaching the entire head and neck area. Hippocrates also noted the association between headache and various activities such as exercise and intercourse.
Headaches have long been attributed to digestive disturbances and to the flow of bile, one of the digestive juices. Almost 2,000 years ago the Roman physician Galen commented: “How constantly do we see the head attacked with pain when yellow bile is contained in the stomach: as also the pain forthwith ceasing when the bile has been vomited.” Hippocrates, attributing migraine to vapours rising from the stomach to the head, realised that vomiting, when possible, could partially relieve the pain of headache. The vomiting attacks of childhood, often migrainous in nature, are still referred to as “bilious attacks”.
Manuscripts have survived of Hildegard of Bingen (1098-1180) – a nun and mystic of exceptional intellectual and literary powers who was able to replicate her “visions” and left detailed drawings and written accounts of what she experienced. Because the description is so detailed, it gives conclusive evidence that migraine caused her visions.
European medieval treatments of headache included drug-soaked poultices applied to the head, and opium and vinegar solutions. The vinegar in the solution was probably used to open the pores of the scalp, allowing the opium to be absorbed quickly through the skin.
Three hundred years later, in 1672, Thomas Willis introduced the term “neurology”. Willis made extraordinarily accurate observations of migraine, and was aware of the many causes of migraine attacks, including heredity, changes of season, atmospheric states, and diet. Willis also introduced the vascular theory of headache, stated that migraine was caused by vasodilatation, pointing out that headache symptoms were related to slowly ascending spasms beginning at the peripheral ends of the nerves.
Then in the late 1770s, Erasmus Darwin (the grandfather of Charles Darwin), believing that headaches were caused by vasodilatation, proposed the theory of treatment by centrifugation, spinning the patient around in a centrifuge to force the blood from the head to the feet.
In 1873, Edward Liveing published “On Megrim, Sick-headache, and Some Allied Disorders: A Contribution to the Pathology of Nervestorms”, the first major treatise devoted to the subject of migraine, where Liveing published his theory that migraine was a brain dysfunction caused by “nerve storms” originating in the brain. Liveing also believed the relationship of migraine to epilepsy was obvious, both being caused by central nervous system discharges. These views differed greatly from the vascular theory.
William Gowers – known as one of the founders of modern neurology and an eminent physician in the late 1800s – subscribed to the neurogenic theory of headache propounded by Liveing. In 1888 Gowers published the most influential textbook of neurology at the turn of the century, “A Manual of Diseases of the Nervous System”. In his passage on the treatment of migraine, Gowers emphasised the importance of a healthy diet. Gowers also invented the headache treatment that came to be known as the “Gowers mixture”, a solution of nitroglycerin in alcohol combined with other agents. Gowers advocated marijuana to relieve the acute attack of headache. One of the first to divide the treatment of headache into prophylactic and episodic, Gowers advocated continuous treatment with drugs to render attacks less frequent, and treatment of the attacks themselves.
Much headache and migraine research is still based on the actions of receptors in the brain, using the work on immunology and receptors for which Paul Ehlich won his Nobel Prize in 1908.
In the late 1930s, Harold Wolffe was the first person to study headache in the laboratory, performing many laboratory experiments which supported the vascular theory of headache.
Research into migraine and other headaches began at The Prince Henry and Prince of Wales Hospitals in Sydney in the 1960s and rapidly achieved international recognition.
A leading member of the Sydney team, Peter Goadsby (now Professor of Clinical Neurology at University College and Honorary Consultant Neurologist, National Hospital for Neurology and Neurosurgery, Queen Square, London) had undertaken research into the way that the brain controlled blood flow to the scalp and to the brain itself. These studies helped to explain why the arteries open up in migraine and cause severe headaches to throb with each pulse.
The fame of the Department of Neurology at The Prince Henry Hospital rested on research into headache and movement disorders. The discovery that a chemical agent serotonin was discharged from blood platelets at the onset of migraine explained a report from America that the intravenous injection of serotonin caused the headache. This was confirmed at Prince Henry but too many side-effects were experienced by the patients to make this an acceptable treatment.
These observations attracted the attention of Dr Patrick Humphrey in the United Kingdom and stimulated him to find a substance that had the beneficial effects of serotonin while minimising the possibility of unpleasant side-effects. Thus were the triptans born – Imigran, Naramig, Zomig – that have improved the life of so many migraine sufferers. The research laboratory at Prince Henry continues to make advances in the knowledge of pain pathways in the brain to answer the question “Why and how does the head ache?”.
Slide Presentation – Professor James Lance
Migraine and Other Headaches 2000 Professor James Lance
Prepared by Louise Alexander, PhC, Grad Dip Comm Mngt, Former National Director of the Brain Foundation. Reviewed by Professor James Lance, AO, CBE, MD, Hon DSc, FRCP, FRACP, FAA, Consulting Neurologist, and author, “Migraine and Other Headaches”