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. Eulenburg7 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.
7 Ziemssen's Cyclopædia, vol. xiv. p. 5.
Age has a decided influence on the production of migraine. Sometimes 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, Tissot8 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.
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, 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.