A system of practical medicine. By American authors. Vol. 5

by Unknown

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. Anstie⁹ 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.

⁹ Op. cit., p. 182.

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. Eulenburg¹⁰ 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.

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 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.