Introduction – The History of Headache

Seymour Diamond1,2 and Mary A. Franklin2,    1Diamond Fellowship and Educational Foundation, and Diamond Headache Clinic, Chicago, Illinois,    2National Headache Foundation, Chicago, Illinois, USA

The history of headache, starting with the earliest records from Mesopotamia, and continuing through Hippocrates, Aerateus, and Galen, provides a glimpse into a malady that has endured through several millenia. In this chapter, we also explore the history of headache treatment from the ancients, through the Middle Ages, and to the end of the 19th century. Finally, we explore the development of the remarkable innovations in pharmaceutical therapies during the late 20th and early 21st centuries.

Keywords

discarded therapies; major discoveries; headache pioneers; ancient remedies

Introduction

In a previous monograph with my editorial collaborator, Mary Franklin, we reviewed the history of headache through the ages – in the arts and literature.1 In this comprehensive work on headache, I would be remiss to not update the history of the advances in headache medicine during the 20th and early 21st centuries.

The history of headache treatment did not start with the discovery of the triptans. The approval of propranolol for the indication of migraine prophylaxis was not the nascent event for migraine prevention; neither was the introduction of dihydroergotamine into the migraine armamentarium. When Bayer started manufacturing acetylsalycilic acid for pain prevention, that was just one step in the long struggle for effective migraine and headache treatment, which has blossomed in recent years.

The Ancients

The earliest mention of headache can be found in Mesopotamia (modern-day Iraq), dating from 4000 BC. When the Ancients experienced headache, they blamed their affliction on Tiu, the evil spirit of headache. Our knowledge of the ancient Egyptians’ headache management is found in the Ebers Papyrus, a collection of medical texts, named for the German Egyptologist George Ebers (1837–1898) who had acquired it. This papyrus contains the earliest written reference to the central nervous system and brain. For headache, the recommended treatment includes a combination of frankincense, cumin, ulan berry, and goose grease, to be boiled together and applied externally to the head.

The Egyptians also attributed the cause of headache as the work of an evil spirit. For those experiencing a “warmth in the head,” the application of moistened mortar to the head was suggested. Another therapy was derived from Egyptian mythology – a combination of coriander, wormwood, juniper, honey, and opium. For joint pain, the Egyptians recommended a mixture of myrtle and willow leaves. The use of willow leaves is cited in treatment for an inflammatory condition: “… you must make cooling substances for him to draw the heat out … leaves of the willow.” Salicylic acid is derived from willow bark, and its use led to the discovery of aspirin. Later, the Assyrians, using stone tablets, recommended the use of willow leaves for treating inflammatory rheumatoid disorders, such as arthritis.2

The Greeks were the next to espouse willow bark as a treatment for pain. Hippocrates (4th or 5th century BC) recommended the extract of willow bark for headache pain. As we know, the teachings of Hippocrates formed the basis of medicine for centuries in the Greek and then the Roman Empires.

At Alexandria, Egypt, the Greeks established a center for medical education and practice. Once the Romans conquered this area, they maintained the center. Aretaeus of Cappodocia (AD 81–138) was probably educated at Alexandria and practiced medicine in Rome. He was the first to distinguish migraine from general headache, noting migraine’s unilaterality, periodicity, and the associated symptom of nausea.3 Aretaeus divided all diseases into acute and chronic. For headache, he described headaches of short duration, lasting a few days, as cephalalgia. The term “cephalea” referred to headaches which lasted longer. Because of migraine’s one-sided occurrence, Aretaeus named it Heterocrania, meaning “half-a-head.” The recommended treatment for headache by this ancient physician was counter-irritation in the form of application of blisters to the affected area, which had been shaved. In Aretaeus’ repertoire of blister agents were pitch, peilitory, euphorbium, lemnestis, or the juice of the thapsia.

During the 2nd century AD, Galen (131–201) gained prominence in Rome. Like Aretaeus, he was trained in Hippocratic medicine and became the court physician to Commodus, the heir of Marcus Aurelius. He is credited with describing migraine as Hemicrania.4 Galen further advanced counter-irritation as a treatment for headache when he proposed the use of the electric torpedo fish applied to the forehead. This form of therapy foreshadowed the use of electrotherapy by Duchenne (1806–1875) and the transcutaneous electric stimulator (TENS) introduced in the late 20th century for all types of chronic pain.

The Middle Ages

The use of trephination for headache treatment was described by Paul of Aegina (625–690), who practiced in ancient Alexandria. The procedure, removing a circular portion of the skull, was believed to disturb the evil spirits which were causing the headache pain and allow them to escape through the wound (Figures 1.1, 1.2).

The fall of the Roman Empire did not mean the end of ancient Greek and Roman medicine. Those early texts on medicine influenced Arab physicians throughout the Islamic world from the 7th century and beyond. One of the most prominent of these physicians was Avicenna (980–1037). A native of Persia (modern day Iran), his textbook, The Book of Healing, was used by his contemporary Islamic physicians but was also available as a Latin translation for the scientists in Europe. Avicenna noted that headache location could vary between frontal, occipital, or generalized, and that one-sided headaches could be provoked by smells. He used cashews as a remedy for headache as well as other neurological and psychiatric disorders. Other Arab physicians wrote of treating headache, epilepsy, and syncope with anomum nelegueta, an African ginger.

In Cordoba, Spain, Abulcasis (935–1013) was physician to the Spanish caliph and was considered the greatest of Islamic medieval surgeons. His book, Kitab al-Tasrif, remained the leading textbook on surgery for the next five centuries in Europe and the Middle East. Abulcasis recognized the importance of the physician–patient relationship. Also, he advised his students to observe individuals closely in order to establish the appropriate diagnosis and select the most effective therapy. His recommended therapy for headache was extreme – applying a hot iron to the head of the individual with headaches. Another headache intervention that he suggested was an incision made to the temple, and application of garlic to the wound.

In addition to its prominence in the Islamic world, Cordoba was also known as the birthplace of the medieval Jewish scholar and physician Maimonides (1135–1204). He studied medicine at Fez, Morocco, and later settled in Egypt, serving as court physician to the Sultan, Saladin, during the first crusade.5 Maimonides’ works on medicine continue to be studied, and it is apparent that he was influenced by Hippocrates and Galen. In his work on headache, Maimonides recognized various triggers of headache, including extremes of cold and heat, caused by changes in barometric pressure.

For headache treatment, Maimonides recommended that those suffering from a “strong midline headache, secondary to thick blood or internal coldness” could benefit from consumption of undiluted wine either during or after a meal. The warming effect of the wine would help, and also would thin the blood. Maimonides also instructed individuals with headache to refrain from physical exertion and other activities until their headache resolved. He cautioned that certain foods which were “rich in moisture” should be avoided, including melons, peaches, apricots, mulberries, fresh dates, etc.6 For milder headache, Maimonides did not believe medication was appropriate, believing nature could relieve this pain without assistance.

During the same period, in what is now modern Germany, a remarkably intelligent and creative nun, the Abbess Hildegard of Bingen (1098–1179), became prominent in the Church because of her preaching. She is also remembered for her religious music and several texts that she wrote on a variety of subjects. In the world of headache medicine, she is known for the illuminated manuscripts that she created from her “visions,” but which have been described as excellent depictions of migraine auras.7 Hildegard lived in a area of Germany near the Rhine...