- From Trepanation to Bloodletting
Archeologists have found evidence of primitive headache remedies dating as far back as 7000 BC. Headaches, in the past, were often thought to be caused by evil spirits. In ancient times, common treatment consisted in a combination of prayers and offerings and by administering strong smelling ointments to the head to chase the spirits away.
For severe headaches, a standard treatment involved trepanation, or in other words, drilling a hole in the skull, which was well known to release from the victim the demon responsible for headaches. This practice was also common for other disorders such as epilepsy. Written evidence mentioning migraine, nerve pain and shooting head pain has been found as early as 1200 BC in the Ebers Papyrus.
Around 600 BC, ancient physicians started to be more interested in physical causes for headaches and developed new surgical procedures and remedies as the belief in magic and spirits became less prominent. For example, Hippocrates was one of the first ancient physicians to record the symptoms associated with migraine in 400 BC, such as visual aura. He also noted the location and evolution of the pain during a migraine and thought that noxious vapors coming from the liver to the head were the cause of headaches. However, it was not until the 2nd century AD, that the symptoms of migraine were fully described by the greek physician Aretaeus of Cappadocia. His reports of symptoms associated with one-sided headaches such as vomiting gave him the title of the “discoverer of migraines”. At the same time, the Chinese physician Hua Tuo used acupuncture successfully for the first time to treat recurrent migraines. The word migraine was used for the first time in the 3rd century AD by the Greek physician and surgeon Aelius Galenus in the roman Empire. The word was derived from “hemicrania” in Latin.
In the Middle Ages, new remedies such as bloodletting, the use of hot irons or even inserting garlic into an incision made in the temple become common practices to treat headaches.
- The First Breakthroughs in the Understanding of Headache: The Emergence of the Vascular Theory of Headaches
The 16th century scientific revolution sparked the first breakthroughs in the understanding of headache pain. The treatment and observation of headaches was increasingly noted in medical literature.
Thomas Willis, also known as the father of clinical neuroscience, came up with the term neurology in 1672 and explored the idea for the first time that vasodilation was responsible for migraine. This has become known as the Vascular Theory of Headaches.
Willis studied other potential causes of migraines and found out that heredity, diet and seasonal and atmospheric changes could lead to a migraine.
In the late 1770s, Erasmus Darwin, who also supported the theory of vasodilation, recommended centrifugation as treatment for headaches because it forced blood from the head to the feet therefore favoring the constriction of vessels in the brain and decreasing the pain. The “centrifuge” apparently relieved pain for at least a few of Dr. Darwin’s more daring patients!
- The Clash of Theories!
This Vascular Theory of Headaches was largely accepted until 1873, when Edward Liveing published On Megrim, Sick-Headache and Some Allied Disorders, in which he explained a new theory. According to him, an overactive central nervous system and “nerve storms” could be responsible for the development of a headache. This led to a debate among physicians as to which theory was correct.
In the late 1800s, the physician William Gowers was among the first to separate headache treatment into acute and preventive. He believed that continuous long term treatment could reduce the frequency of headache attacks but also thought that marijuana could relieve the pain of undergoing attacks.
- Taking Headache to the Lab: Standing on the Shoulders of Giants
Dr. Harold G. Wolff was a pioneer in the field of headache research. In the 1930s, Wolff undertook the first study of headaches in a laboratory setting. Along with his fellow scientist, John Graham, Wolff determined that ergotamine tartrate could alleviate the pain of migraines. They found that it caused the vasoconstriction of dilated blood vessels in the brain, which confirmed the Vascular Theory of Headaches. Wolff also performed a number of experimental studies that linked vasodilation to headaches.
Wolff’s work was influential in headache history and led to the systematic use of experimental research for the study of the mechanisms behind headaches. A few decades later, research showed that serotonin could have a role in the onset of migraines and in the 1950s, scientists discovered that the drug methysergide, a serotonin antagonist, demonstrated effectiveness in preventing migraine attacks.
On a personal note we might add that Dr. Wolff pursued medical studies at New York’s Roosevelt Hospital, where our Dr. Broner completed her Fellowship in Headache. Dr. Wolff went on to become Chief Neurologist at New York Hospital – Cornell Medical Center, where Dr. Broner is now proud to be affiliated.
- Understanding Biological Pathways and Beyond
In the 1980s, the publication of the ICHD established official diagnostic criteria for headache disorders. But it was not until the 1990s that specific genes involved in certain headache disorders were identified. It was around this time that migraine started to be understood as a neurovascular disorder with a complex pathway. This meant that altering this biochemical pathway could help treat headaches.
Research on this biochemical pathway led to the development of migraine specific triptan medications. Triptans target serotonin receptors in the brain. Serotonin levels decrease at the beginning of a migraine attack, leading to the dilation of the blood vessels in the brain and the swelling of the surrounding tissues. This effect, in turn, causes pain.
By targeting serotonin receptors, triptans can stimulate the receptors, counteracting the decrease in serotonin level. This should lead to the constriction of the dilated blood vessels in the brain, decreasing the pain and the associated symptoms. Additionally, triptans may also act directly onto other areas of the brain involved in the propagation of migraine pain.
Leading figures in the understanding of headache have included Rami Burstein, Ph.D., of Harvard, Mike Moskowitz, MD, at Massachusetts General Hospital and Peter Goadsby at King’s College, London.