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

by Unknown

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 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.