Freud and migraine: the beginning of a psychodynamically oriented view of headache a hundred years ago

Migraine and reproductive life

Migraine is prevalent in women during the fertile age. Indeed, both neuroendocrine events related to reproductive stages (menarche, pregnancy, and menopause) and menstrual cyclicity and the use of exogenous sex hormones, such as hormonal contraception and replacement therapy, may cause significant changes in the clinical pattern of migraine. Menstrual migraine may be more severe, long-lasting, and refractory to both acute and prophylactic treatment and, therefore, requires tailored strategies. The use of headache diaries, which makes it possible to record prospectively the characteristics of every attack, is of paramount importance for evaluating the time pattern of headache and for identifying a clear link with menstrual cycle-related features. Estrogen variations are highly implicated in modulating the threshold to challenges by altering neuronal excitability, cerebral vasoactivity, pain sensitivity, and neuroendocrine axes throughout the menstrual cycle and not only at the time of menstruation. On the other hand, estrogen withdrawal may really constitute a triggering factor for migraine in women with peculiar characteristics of vulnerability with menstruation or following the discontinuation of exogenous estrogen, as happens with hormonal contraception during the fertile age or with hormone therapy at menopause. In addition, exogenous estrogen may contribute to the occurrence of neurological symptoms, such as aura. When aura occurs, hormonal treatment should be discontinued.

A history of non-drug treatment in headache, particularly migraine

Although new invasive procedures for the treatment of migraine have evolved during the past decades, the application of invasive procedures for this indication is not new. In this review, the history of non-drug treatments for migraine is discussed. Historical texts by physicians known to have written on headache and migraine (hemicrania), well-known books by physicians from the main historical periods up to 1900 and mainstream 20th century neurology handbooks were analysed. A large number of treatments have been tried, based on contemporaneous pathophysiological models that were not only applied to headache, but to medicine in general. Invasive procedures have been used for the more severe types of headache. Many treatments were based on ancient humoral theories up to the early 19th century. A new kind of invasive procedure appeared on the physician's palette in the 19th and 20th century, following the development of new ideas that were based on solid pathophysiology, after the introduction of scientific method into medicine. After its introduction in the mid-18th century, medical electricity became even more popular for the treatment of migraine following the discovery of vasomotor nerves in the mid-19th century, but at the end of that century a more critical attitude appeared. The discovery of the lumbar puncture (1892) and roentgenogram (1895) and increased knowledge of intracranial pressure led to a new series of invasive procedures for therapy-resistant migraine in the early 20th century. Vasospastic theories of migraine led to surgical procedures on the sympathetic nerves. Following the experiments by Graham and Wolff in the 1930s that emphasized the vasodilatation concept of migraine, sympathicolytic procedures again became popular, including vessel ligation of the carotid and middle meningeal arteries. The influence of suggestion and psychological phenomena recognized at the end of the 19th century probably played an important role in many of the procedures applied. These placebo effects, generally more powerful in invasive treatments, are discussed against the background of present-day invasive treatments for headache, where they are still a matter of concern.

Hormonal management of migraine at menopause

In this review, we underline the importance of linking migraine to reproductive stages for optimal management of such a common disease across the lifespan of women. Menopause has a variable effect on migraine depending on individual vulnerability to neuroendocrine changes induced by estrogen fluctuations and on the length of menopausal transition. Indeed, an association between estrogen 'milieu' and attacks of migraine is strongly supported by several lines of evidence. During the perimenopause, it is likely to observe a worsening of migraine, and a tailored hormonal replacement therapy (HRT) to minimize estrogen/progesterone imbalance may be effective. In the natural menopause, women experience a more favourable course of migraine in comparison with those who have surgical menopause. When severe climacteric symptoms are present, postmenopausal women may be treated with continuous HRT. Even tibolone may be useful when analgesic overuse is documented. However, the transdermal route of oestradiol administration in the lowest effective dose should be preferred to avoid potential vascular risk.

The pathogenesis of migraine - 17th to early 20th century understandings

The modern understanding of the pathogenesis of migraine, based on the concept that it is a neurovascular disorder, is often thought to have emerged from the work of Harold Wolff in the period 1932-1962. However, over the preceding 300 years, from William Harvey onwards, various hypotheses of the pathogenesis of migraine had been proposed, a few bearing reasonably strong resemblances to Wolff's ideas, though based on less adequate evidence. Many of these earlier hypotheses regarded migraine either primarily as a vascular (e.g., Willis, Wepfer, Latham) or as a neural disorder (e.g., Harvey, Lieving and his 'nerve storms'). There were also variations around these two major themes and in the 19th Century a number of neurovascular type hypotheses emerged assigning a major role in migraine pathogenesis to the autonomic nervous system. In addition, during the three centuries there were a number of other hypotheses based on different postulated pathogenic mechanisms, some quite ingenious, which had relatively brief vogues. No hypothesis has yet proved capable of explaining all the features of migraine satisfactorily.

Headache and psychiatric comorbidity: historical context, clinical implications, and research relevance

The comorbidity of headache and psychiatric disorders is a well-recognized clinical phenomenon warranting further systematic research. Affective disorders occur with at least three-fold greater frequency among migraineurs than among the general population, and the prevalence increases in clinical populations, especially with chronic daily headache. When present, psychiatric comorbidity complicates headache management and portends a poorer prognosis for headache treatment. However, the relationship between headache and psychopathology has historically been misunderstood, and measures of psychopathology have not always met the standard of formal Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria. In some cases, headache has been inappropriately attributed to psychological or psychiatric features, based on anecdotal observations. The challenge for future studies is to employ research methods and designs that accurately identify and classify the subset of headache patients with psychiatric disorders, evaluate their impact on headache symptoms and treatment, and identify optimal behavioral and pharmacologic treatment strategies. This article offers methodological considerations and recommendations for future research including: (i) ascribing dual-International Classification of Headache Disorders, 2nd ed. (ICHD-2) headache and DSM-IV psychiatric diagnoses according to reliable and valid diagnostic criteria, (ii) differentiating subclinical levels of depression and anxiety from major psychiatric disorders, (iii) encouraging validation studies of the recently published ICHD-2 diagnoses for "headache attributed to psychiatric disorder," (iv) expanding epidemiological research to address the range of DSM-IV Axis I and II psychiatric diagnoses among various headache populations, (v) identifying relevant psychiatric and behavioral mediator/moderator variables, and (vi) developing empirically based screening and treatment algorithms.

Great pains: famous people with headaches

Have headaches influenced the course of history? It is very difficult to prove, but there is no doubt that head pains have affected some of the most influential people in history. This review explores how headaches have affected some of the world's most famous people.