This form of headache is of great importance, from the frequency with
which it is met in practice. It occurs in paroxysms at longer or
shorter intervals, but the attacks come at periods of tolerable
regularity, and, generally speaking, the intervals are entirely free
from pain. From the name hemicrania it may be inferred that the pain
is confined to one side of the head. This is often the case, but is
not invariably the rule.
Migraine has been known for many years, and the term hemicrania is
used by the old writers. Until recently, however, there has been some
confusion regarding it. Hemicrania often meant trigeminal neuralgia,
and nervous sick headache was generally believed to have its origin in
the stomach or to be the result of biliousness. Of late years the
disease has come to be better understood, and the valuable works of
Liveing, Anstie, and others have given a full literature of the
subject.
Various conditions predispose to migraine, and of these the foremost
are period of life and hereditary influence. Sex also bears a part in
the etiology. The majority of patients who are victims of migraine are
females. Eulenburg[7] states that the proportion is about 5 to 1 in
favor of females. My own experience would lead me to believe that in
this country the preponderance of migraine in females is not so great.
Men are not so likely to consult a physician about headaches, unless
they become very frequent and severe; especially is this true of the
laboring classes, from whom Eulenburg's statistics were mainly taken.
It is true that women are especially prone to neuroses of various
kinds through menstrual disorders and at the time of the climacteric,
but these do not always take the form of migraine.
[Footnote 7: _Ziemssen's Cyclopædia_, vol. xiv. p. 5.]
Age has a decided influence on the production of migraine. Sometimes
{407} the attacks begin in very young children. Eulenburg mentions
cases at four or five years. It is during the period of bodily
development that the first outbreaks of migraine occur, but more
particularly do they set in in both sexes at puberty, a time when
sexual development is active and making a strong impression on the
whole nervous system. Should migraine become established at this time,
it will probably continue to harass the individual until he is
forty-five or fifty years of age. After the development of puberty
migraine is not likely to originate; indeed, Tissot[8] declares that a
person who is not attacked by migraine before his twenty-fifth year
will escape from it for the rest of his life. It certainly is the case
that in later life this affection is much more rare than earlier, as
many of the old cases get well and new ones scarcely ever develop. It
is a common thing to hear a patient who has reached the age of fifty
extolling some new system or remedy as a cure for his headaches, from
which he has suffered all his life, when in reality the attacks have
ceased or become infrequent on account of the natural course of the
disease.
[Footnote 8: Quoted by Eulenburg, _op. cit._]
Hereditation markedly affects the production of migraine. Eulenburg
states that it follows the female line, and is inherited from the
mother only; but this is surely a mistake, as we often see males whose
fathers suffered from migraine. Persons whose ancestors were of a
neurotic type, who suffered from neuralgias, paralysis, hysteria,
insanity, etc., are particularly liable to migraine. Epilepsy is also
likely to be in the family of an individual who has migraine. There
has been observed by many writers the association of migraine and
epilepsy in the same person. Epileptics who are predisposed to the
disease by inheritance are likely to have attacks of it preceding the
outbreak of epilepsy. In families of constitutional nervous tendencies
it is common to see certain members who have hemicrania, while others
have epilepsy or are insane.
Other predisposing causes in migraine are not so marked as those
already mentioned. Station in life exerts but little influence in the
causation of the disease. It is met with as often in the laboring
classes as in the wealthy. Those who use the brain to any extent in
study or business are likely to suffer more often from migraine than
those who lead an outdoor life with much physical exercise. Habitual
loss of sleep and anxiety also predispose to it.
As to the conditions connected with the immediate production of an
attack of migraine, we are in ignorance. It has been thought to depend
upon disorders in the circulation of the blood, but then the question
arises, Whence these disturbances of circulation? Probably those
circulatory disorders which are marked in every case are effect rather
than cause of the attack. Indigestion and biliousness must be admitted
to favor outbreaks of migraine.
SYMPTOMS.—Migraine occurs at intervals of one or two weeks or longer;
often the attacks are not more frequent than every month or even two
or three months. I have seen a number of patients who have attacks of
migraine on Sunday with regularity, and escape during the interval.
Some of these cases ascribed the attacks to sleeping later on this day
than on others, but it is more likely that the attacks were the result
of the culminating effect of a week's hard work. Between the attacks
the patient is usually quite well as far as headache is concerned,
{408} but he may have slight neuralgia in branches of the trigeminal.
The attacks are more or less alike. They are often preceded by
prodromal symptoms for a day or two. The patient may feel languid or
tired for a day before the attack. Sometimes there is unusual hunger
the night before a paroxysm, or there may be violent gastralgia before
each attack. The patient often wakes in the morning after sound sleep
with a pain in the head. Should the attack come on in the day, it may
be preceded by chilliness, yawning, or sneezing and a sense of general
malaise. Ocular symptoms are frequent as a forerunner of an attack.
First muscæ volitantes are seen, then balls of fire or bright zigzags
appear before the eyes, making it impossible for the patient to read.
These symptoms last for a few minutes or a half hour, and then cease,
to be immediately followed by pain. Hemianopsia is a precursory
symptom of rather frequent occurrence. Ross mentions a case in which
the hemianopsia usually lasted about a half hour, and was followed by
severe hemicrania. The ocular symptoms are often very alarming to
patients.
The pain, as a general rule, is at first in the ophthalmic division of
the fifth nerve and its branches. It may begin in the branches of the
occipital nerve or in the parietal region. It comes on gradually, is
dull and boring at first, but becomes more intense and spreads to one
lateral half of the head, more especially the front part. As it
increases in intensity the pain seems to involve the entire head.
Either side of the head may be affected. Eulenburg thinks that the
left side is attacked twice as often as the right. An individual may
have the pain on opposite sides of the head alternately in different
attacks. The pain is described by patients as dull and boring or
intense, and the head feeling as if it would burst. Patients often
make pressure on the head to obtain relief. At times the pain seems to
be of a violent, throbbing kind, keeping time, as it were, with the
pulsation of the arteries. Lying down usually relieves the pain, but
if it is violent the recumbent position seems to favor the afflux of
blood to the head, and thereby increases the pain. The eye of the
affected side becomes bloodshot, and the tears stream from it. The
eyelid droops, and the sight is dim and clouded or may fail entirely.
The least light is unbearable. During the attack the subject is chilly
and intensely depressed, and the feet are very cold. The pulse is at
first slow, small, and compressible.
Painful points (Valleix's points) are not present, but there is
usually tenderness over the supraorbital notch during an attack of
migraine, and after the paroxysm there is a general soreness of the
scalp and forehead. Sometimes there remains a tenderness of the parts
surrounding the affected nerve. This is not in the nerve itself, but
in the adjacent tissues. Anstie[9] says that in his own case, after
repeated attacks of migraine, the bone had become sensibly thickened
in the neighborhood of the supraorbital notch. There is sometimes
hyperæsthesia of the skin in the affected regions of the forehead and
scalp during an attack. As well as hyperæsthesia, there may be an
abnormal acuteness of the sense of touch. Deep pressure over the
superior and middle ganglia of the sympathetic causes pain, according
to Eulenburg. This observer also states that the spinal processes of
the lower cervical and upper dorsal vertebræ are painful on pressure.
[Footnote 9: _Op. cit._, p. 182.]
{409} During the attack of migraine there is complete loss of
appetite, and any food that may be taken remains undigested in the
stomach for hours. As the pain intensifies there comes on a sense of
nausea, there is a profuse flow of saliva, and large quantities of
limpid urine are passed. Finally, when the pain seems to have reached
its maximum, vomiting occurs. Immediately afterward the pain is
greatly increased, but this is the result of the increased amount of
blood in the cranial cavity from straining. Soon after, the patient is
easier, and falls into a sleep, from which he awakes free from
headache. The crisis is not always accompanied by vomiting. In some
instances there is no nausea, but at the acme of the pain there are
two or three profuse diarrhœic stools, after which the pain is
relieved. I have lately seen such a case in a young man of
twenty-three years of age. Sometimes there is only a profuse sweat or
large flow of urine.
During the attack there are disorders of the circulation. The pulse
may be intermittent or irregular, and the extremities are usually
cold. Disorders of cutaneous sensibility are also often present. A
condition of numbness confined to one lateral half of the body is
sometimes experienced during the early part of the paroxysm. This
numbness is noticed even in one half of the tongue.
The German writers have divided migraine into two types, and the
arrangement may be followed in some instances. The first is called
hemicrania spastica or sympathico-tonica. In this form there is
supposed to be vascular spasm and a diminished supply of blood in the
brain. The symptoms are as follows: When the attack has reached its
height the face is pale and sunken; the eye is hollow and the pupil
dilated; the arteries are tense and feel like a cord. The external ear
and the tip of the nose are cold. Eulenburg[10] states that by actual
measurement he has found the temperature in the external auditory
meatus fall 0.4° to 0.6° C. The pain is increased by stooping,
straining, or anything which adds to the blood-supply in the head. At
the end of the attack the face becomes flushed and there is a sense of
heat. The conjunctiva becomes reddened, the eye is suffused, and the
pupil, which had been dilated, contracts. The sense of warmth becomes
general, the pulse is quickened, and the heart palpitates. The crisis
is reached with vomiting and a copious flow of urine or perhaps a
diarrhœic stool. There is sometimes an abundant flow of saliva. One
observer has reported that he has estimated a flow of two pounds of
saliva during an attack.
[Footnote 10: _Op. cit._]
The other variety is termed hemicrania angio-paralytica or
neuro-paralytica. Here we find the opposite condition of things from
that met with in hemicrania spastica. There is marked increase in the
amount of blood in the brain. When the attack is at its height the
face on the affected side is flushed deeply, hot, and turgid. The
conjunctiva is injected, the lachrymal secretion increased, and the
pupil contracted. Sometimes there is slight ptosis. The ear on the
affected side is hot and red. The temperature of the meatus may rise
0.2° to 0.4° C. The temporal artery is swollen, and throbs with
increased force. The carotid beats visibly. There is free
perspiration, which is sometimes unilateral. Compression of the
carotid on the painful side relieves the pain, while pressing on the
opposite carotid makes it worse. The heart beats {410} slowly, the
pulse being sometimes as low as 48 to 56. At the end of the attack the
face becomes paler and the other symptoms subside.
There are many cases in which the vascular conditions present no
peculiarities during the attack, and which cannot be classed with
either of the varieties just described.
In all forms, if the patient can be quiet, he usually falls asleep
after the crisis has been reached, and awakes free from pain, but
feeling haggard and prostrated.
The paroxysm lasts for several hours, generally the greater part of
the day. It may last for several days, with variations of severity.
The attacks are at longer or shorter intervals of time, and in women
they often appear at the menstrual period. The attack may be brought
on by over-mental or bodily exertion, imprudence in eating or
drinking, and exposure to cold draughts of air. It will often begin as
a supraorbital neuralgia from exposure to cold, and go on through all
the phenomena of a regular migraine.
Seizures are often brought on by fatigue, and there are some persons
who invariably have a violent attack of migraine after a journey.
Nursing women are liable to more frequent paroxysms, and I have
recently seen a lady who within a few days after delivery after both
of her confinements suffered from typical attacks of migraine,
although during gestation she had escaped them.
DIAGNOSIS.—Migraine can readily be distinguished from the other forms
of headache by the comparative regularity of the attacks and its
numerous other characteristics. It differs from neuralgia in the pain
being less acute and shooting. The pain of migraine is more dull and
throbbing, and extends more generally over the head. The ocular
phenomena are more or less constant in migraine and do not occur in
neuralgia.
PROGNOSIS.—Migraine is never fatal, and usually becomes less severe
and less frequent as middle life is reached. Some patients continue to
suffer from it during their entire life, and often when the typical
migraine has ceased it is replaced with paroxysms of neuralgia.
Therapeutic and hygienic means are of decided influence in the course
of the disorder, and many patients experience great relief or
temporary immunity from attacks as a result of treatment. Cases of
long standing and those of an hereditary type are most unfavorable as
to relief from treatment or by spontaneous cure.
PATHOLOGY AND MORBID ANATOMY.—Migraine not being a fatal disease, we
know nothing of the changes which exist in the brain; we can only
surmise what are the conditions which exist in the brain during and
before an attack.
It is evident that there is a strong relationship between migraine and
neuralgia of the trigeminal nerve, and if we study the symptoms of the
two conditions, and consider the causes which produce attacks of each,
we cannot but arrive at the conclusion that migraine is a variety of a
neuralgia of the ophthalmic division of the fifth. The late Anstie has
most clearly and forcibly given his reasons for believing this to be
the case, and we cannot but uphold his view.
Migraine is constantly met with in early life as the type of a
neuralgia which in later years loses the special features of a sick
headache and becomes {411} a pure neuralgia. The same forms of trophic
lesions may occur in migraine and in trigeminal neuralgia. Anstie
instances his own case, in which in early life he had distinct attacks
of migraine, with corneal ulceration, orbital periostitis, and
obstruction of the nasal duct, while later in life his attacks were
only neuralgic, without any stomach complications.
Migraine, as already remarked, attacks early life especially at the
time of sexual development, and the same is true of epilepsy. There is
also the same hereditary predisposition to the former as to the
latter. Patients who have migraine belong often to families other
members of which suffer from epilepsy, chorea, and an uncontrollable
tendency to alcoholic excesses. Indeed, occasionally migraine and
epilepsy are interchangeable in the same individual. Many cases of
epilepsy have suffered at some time of their lives from severe
headaches.
Hughlings-Jackson describes the attacks of migraine as arising from a
discharging lesion of the cortex of the brain in the sensory area, or
in that part of it which corresponds to the region of pain in the
head. Genuine epilepsy he holds to be due to a discharging lesion from
the motor area of the cortex. During an attack of migraine the
discharging lesion does not remain confined in the sensory portion of
the cortex, but extends into the medulla oblongata and the
cilio-spinal region of the cord, causing irritation or paralysis of
some of these centres, and causing the vaso-motor and oculo-pupillary
symptoms which are conspicuous during an attack.
In the form of migraine known as hemicrania sympathico-tonica there is
tonic spasm of the vessels of one side of the head. This explains the
pallid face, the lowered temperature, and the sunken eyes. After the
cause of the contraction is removed, then the vessels relax and the
amount of blood-supply greatly increases. Hence the redness of the
conjunctiva, lachrymation, and redness of the ear at the close of an
attack. The vomiting is explained by Eulenburg as being due to
variations in the intracranial blood-pressure. This causes fitful
contractions of the vascular muscles, alternating with partial
relaxation. These conditions must arise in the sympathetic nerve of
the corresponding side.
The dilation of the pupil during an attack depends upon irritation of
the cervical sympathetic ganglia. Other symptoms, such as the largely
increased flow of saliva and the flow of tears or drying of the
Schneiderian mucous membrane, indicate a morbid condition of the
cervical sympathetic. The sensitiveness to pressure in the region of
the upper cervical ganglia and over the spinous processes of the lower
cervical and upper dorsal vertebræ, corresponding to the cilio-spinal
region of the cord, confirms the idea of a morbid state of the
cervical sympathetic.
In hemicrania angio-paralytica there is supposed to be a relaxed
condition of the vessels of one side of the head. Here, instead of an
irritation of the sympathetic, there is a paralytic condition, and we
have the same results as are seen in animals when the cervical
sympathetic is divided. There seem to be good grounds for holding this
view when we consider the flushed face, contracted pupil, retraction
of the eyeball, and occasional ptosis which accompany this form of
headache. Possibly there may be a brief stage of spasm of the vessels
preceding the relaxation which occurs in hemicrania angio-paralytica.
{412} The slowing of the pulse during an attack of migraine is due
probably to cerebral hyperæmia from relaxation of the vessels, or to
the secondary anæmia and irritation of the medulla oblongata. This
irritation of the medulla is also able to explain the other symptoms
of vaso-motor disturbance which occur during an attack of migraine;
for instance, the small and contracted radial artery, the extreme
coldness of the hands and feet, and the suppression of perspiration
over the whole body except perhaps on the affected side of the head.
Following the stage of irritation of the medulla with contraction of
the vessels comes one of exhaustion with relaxation of the vessels.
This latter state may account for the profuse flow of saliva and the
copious secretion of sweat and urine, as well as the increased
secretion of bile and the condition of broncho-tracheal catarrh during
the attack.
We now come to the question of the origin and seat of the pain in
migraine. This question has involved a great deal of thought, and has
been answered in various ways by different writers. E. du Bois-Raymond
thought that the pain was due to tonic spasm of the muscular coats of
the vessels, and that thereby the nerves in the sheaths of the vessels
were pinched, as it were, and so caused pain. Moellendorff was of the
opinion that the pain was due to dilatation of the vessels, and not to
contraction; and this theory might explain the pain in the
angio-paralytic form. There are many cases in which neither of these
views is sufficient, for we have no reason to believe that a condition
of either anæmia or hyperæmia is present.
Romberg believed that the pain was situated in the brain itself, and
Eulenburg holds that the pain must be caused by alterations in the
blood-supply, without regard to their origin, in the vessels of one
side of the head. He thinks that the vessels may contract and dilate
with suddenness, just as is often seen in some neuralgias, and thus
intensely excite the nerves of sensation which accompany the vessels.
The increase of pain upon stooping, straining, or coughing, and the
influence upon it by compression of the carotids, seem to give force
to this view. But are we not here confusing cause with effect? Are not
these variations in the calibre of the vessels due to the irritation
of the sensory and vaso-motor nerves, which are in a state of pain? No
doubt increase in the blood-supply augments the pain, just as it does
in an inflamed part when more blood goes to the part. Let a finger
with felon hang down, or let a gouty foot rest upon the floor, what an
intensity of pain follows!
Anstie very ably advocated the theory of migraine being a variety of
trigeminal neuralgia in the ophthalmic division; and we incline
strongly to his view. An attack of migraine often begins with pain
distinctly located in the supraorbital nerve as the result of exposure
to cold. Frequently it begins in the infraorbital nerve or in the
branches of the inferior maxillary division of the fifth. The pain
then spreads over one side of the head, both outside and inside, and
goes through the recognized symptoms of migraine. In my own case I
have often had an attack begin with sharp pain in the supraorbital
notch in a spot which could be covered by the tip of the finger. The
nerve has seemed swollen, and has been highly sensitive to pressure.
Then have come pain extending over the entire side of the head,
without its limits being distinctly definable, and the accompanying
phenomena of lachrymation, excessive salivation, {413} and copious
flow of urine, winding up with vomiting or ineffectual nausea and
retching.
Anstie brings forward as arguments to support his view the facts that
the attacks of migraine often interchange with neuralgic seizures, and
that a person who has been migraineuse in early life may in later
years lose his hemicranial attacks, and have violent neuralgia in the
ophthalmic division of the fifth nerve.
The true seat of the lesion, if we may so call it, upon which the
exaggeration of pain-sense depends, is probably in the nerve-centre;
that is, in that part of the trigeminal nucleus back to which the
fibres go which are distributed to the painful areas. The pain is no
doubt chiefly intracranial, and in those portions of the cerebral mass
and meninges to which branches of the trigeminal are distributed. All
of the divisions of the trigeminus send branches to the dura mater.
Many nerves are found in the pia mater as plexuses around the vessels,
some of which penetrate into the centre of the brain. Most of these
nerves come from branches of the trigeminus.