CHAPTER II HEADACHE (Part 1)

CHAPTER II HEADACHE i, GENERAL CONSIDERATIONS Iw discussing this, probably the commonest of all symptoms, I shall exemplify by cases only such causes as are likely—(a) to be complained of by the patient as his leading symptom, and (8). to occasion diagnostic difficulties. Others will be briefly mentioned here. 1. Anemia of any type—pernicious, chlorotic, posthemorrhagic— is now and then accompanied by headache, usually as a minor symptom. It is noteworthy, however, that intense anemia often persists for months without producing any headache whatever. It may well be doubted whether anemia is ever in itself the cause of headache. 2. Fatigue, hunger, and bad air often produce a headache (perhaps due to the circulation of “fatigue poisons”) whose cause is made obvious by its disappearance after rest, food, and fresh air. 3- Poisons, such as alcohol, morphin, and lead. Except after a drinking bout, I have never known a patient whose chief complaint, as a result of any of these poisons, was headache. Other symptoms usually occupy the foreground. 4. Arteriosclerosis.—It has long been stated in medical lectures and text-books that the headaches of elderly persons are frequently caused by arteriosclerosis. My own experience, however, coincides entirely with that of Thomas, of Walton, and of Paul,? who deny any such asso- ciation. In my experience, it is only when the kidney is extensively involved and blood-pressure thereby raised that headache results from arteriosclerosis. 5. Indigestion and Constipation.—Gastric stasis, arrested digestion, and the resulting abnormal fermentation of food often lead to a head- ache which needs no further mention here. The patient can usually make the diagnosis for himself. The same is often true of the headaches 1 Of 697 cases of pernicious anemia studied by me, 300 had no headache at any time, See Osler’s Modern Medicine, vol. iv, p. 622. ? Walton and Paul, Jour. Amer. Med. Assoc., 1908; Thomas, Osler’s Modern Medicine, vol. vii, p. 336. R Causes of HEADACHE . FATIGUE, BAD AIR, AND HUNGER iy CONSTIPATION AND INDIGESTION (‘‘BILIOUS- & ALCOHOL (THE “DAY AFTER” HEADACHE 4 NTRINSIC DIS OF THE EYE 5. INFECTIOUS DISEASES (ONSET 6. MENSTRUATION 7, PSYCHONEUROSES EEE 13° 8, NEPHRITIS. Ee a 602 9. MENINGITIS ee 172 10. SINUSITIS Pe 157 12.“INDURATIVE” 89 13. MIGRAINE = 89 14, BRAIN TUMOR = 46 15. SYPHILITIC ' 16 PERIOSTITIS! J 16. UNKNOWN CAUSE S=::.Scere aa 619 1 The diagnosis of intracranial syphilis seems to me still so uncertain that I have not included it here. HEADACHE resulting from constipation, miscalled “lithemia,” “biliousnes “torpid liver.” or A remarkable feature of this type of headache is its swift disappear- ance, in certain cases, after defecation. From several very intelligent patients I have heard repeatedly the story of a headache that disup- peared, wholly or mostly, within a few minutes of the time of defeca- tion. This is hard to reconcile with any chemical theory regarding the origin of such a pain. : 6. Many common infections—rhinitis, tonsillitis, the exanthemata, etc.—are often accompanied by headache, which, however, is rarely the patient’s chief complaint. There are other infections—examples of which will be given below—which cause so severe and persistent a head- ache that it becomes the “presenting symptom.” 7. The headache sometimes accompanying olifis media and other forms of aural disease gets its recognition, in the vast majority of cases, from the concurrent aural symptoms. 8. Menstruation is often preceded or’ followed, less often accompanied, by headache the exact origin of which is very obscure. 9. Trigeminal neuralgia, with or without the paroxysms and spasms of tic douloureux, presents, as a rule, no serious difficulties in diagnosis, and will, therefore, not be further mentioned here. Mild types may originate in dental caries or other peripheral irritations. The severer forms appear to be due to changes in the Gasserian ganglion. to, Insolation, with or without actual sunstroke, has often been listed among the causes of headache. In my experience, however, there is usually a large neurasthenic element in these cases, and the history of insolation is often vague and forced. 11. Adolescence is frequently associated with a headache for which no local cause can be found. We connect such headaches vaguely with adolescence, because they pass off with the end of that period. 12. Cerebral concussion—as in a foot-ball game—is a common cause of headache, which usually presents no diagnostic difficulties. 13. Indurative Headache-—“This—probably the most frequent form of headache—seems to be unknown to the majority of physicians, although it has been described in text-books for decades” (Edinger, in Die Deutsche Klinik’). The term “indurative” expresses an attempt to characterize the malady without committing ourselves to any theory regarding its cause or morbid anatomy. In some of the older books it is referred to as 1 Translated under title of Modern Clinical Medicine, in the volume on Diseases of the Nervous System, p. 863, Appleton, 1908. 36 DIFFERENTIAL DIAGNOSIS “rheumatic headache.” JIts distinguishing feature is the presence of painful “indurations” near the insertions of the muscles at the occiput. Bits of the trapezii, sternocleidomastoids, scaleni, or splenii become sensitive, uneven, and nodular, “as if something were deposited in the substance of the muscle.” (See Fig. 1.) Pain which is chiefly, but not exclusively, occipital is associated with these “indurations,”” and disappears when they are removed by mas- sage. It is on this account that the disease is so much better known to Fig. r.—The points upon which indurations are most frequently found (Edinger). the masseurs and to the physicians who have studied and practised massage than to the medical profession at large. Writers on massage do not hesitate to speak of the “indurations” as foci of “chronic myo- sitis,” but there are, so far as I know, no histologic examinations on which we can base such a term. Edinger ' apparently considers the con- dition a neuralgia. Swelling of the neighboring lymph-glands and of the cervical sympathetic ganglia is mentioned by some writers. ‘The sensitiveness to touch extends to the aponeuroses over the skull, 1 P, 865 in the volume above cited. HEADACHE 37 to the vertex and even to the frontal region; also down along the outline of the trapezius on the shoulder. In this as in many other respects it resembles “lumbago” and “stiff neck.” The disease is often referred to as “rheumatic,” becaus: some cases to follow exposure to cold and wet, e. g.: “A few days before the appearance of the symptoms he had been overtaken by a hailstorm while riding a bicycle.” To some these statements still carry convic- tion, é. g., to Edinger, who say ' produce the disease.” I have, I regret to say, no cases in my own experience which exem- plify this disease. I have referred to it here because it seems to me to deserve more careful study by clinicians and because of Edinger’s statement, based on his extensive experience at the Neurological Institute in Frankfurt-am-Main, that it is probably the most frequent form of headache, and that: “The examination of the insertions of the muscles should never be neglected in any case of headache.” 14. Vasomotor Headaches—Though vasomotor disturbances may occur in various types cf headache, especially in migraine, there remains a group of cases in which only the vasomotor trouble (vasoparalysis and vasodilatation) is discoverable as cause. These patients have very red faces in the attack, and usually show reddish blotches or stri@ over the rest of the body. The diagnosis is made by the presence of the above signs and by exclusion of all other known causes. ¢ it seems in “Tt is certain that refrigeration may 2. POSITION AND NATURE OF THE HEADACHE (x) Many text-books map out the surface of the skull with special “headache areas,” reminding one of a phrenologic map, but in my experience there is not often much to be learned from the fosition of a headache. Ocular headaches often begin or center near the eyes; pains due to otitis media often spread from an initial focus near the ear. Inflammations of the antrum or frontal sinus cause pain over the affected cavity. The pain of syphilitic periostitis corresponds with the position of the lesion. Migraine, with its unilateral distribution, and trigeminal neuralgia have also a typical distribution. On the other hand, ocular and aural headache is often not thus localized, and the pain due to any of the other familiar causes (uremia, infection, brain tumor, constipation, menstruation, neurasthenia) may be in any part of the head, and is often unilateral, so as to be mistaken for migraine. (2) The Rind of pain is likewise of very little significance: throbbing, dull, burning, boring headaches are encountered in all sorts of discases. 38 DIFFERENTIAL DIAGNOSIS A sense of constriction and pressure is mentioned by many patients of the psychoneurotic group, especially if they have been to France and have been told that they have a “téte en casque.” (3) The severity of headache is probably greatest in organic diseases of the brain or periosteum (cerebral tumor, meningitis, syphilitic perios- titis), in the paroxysms of tic douloureux, and in those of migraine. (4) Chronic headaches, sometimes lifelong, are associated with all the psychoneuroses (neurasthenia, hysteria, psychasthenia), and are sometimes present without any discoverable cause. They are often referred to the “base of the brain” (meaning the nape of the neck). Blows on the head, sunstroke, arsenical poisoning, and all sorts of “reflex” disturbances (pelvic, ocular, gastro-intestinal) are often vainly invoked as causes, and the term “constitutional” is often attached to such pains, but a frank confession of our ignorance seems to me better. (5) The time of day markedly influences some headaches; those associated with frontal sinus disease often begin at the same hour each morning, last a certain time, and pass off. This is also true of the psy- choneurotic group, but the time of seizure and of relief is much less accurately recurrent. Headaches due to syphilis, to brain tumor, and to uremia are often worse at night, but syphilis has no monopoly of this characteristic. 3. TWO TRADITIONAL FALLACIES ABOUT HEADACHE (a) The belief that physiologic and pathologic states of the female generative organs often produce headache is widespread. Text- books, such as Butler’s, list dysmenorrhea, “ uterine disease,” disease of the ovaries, and even of the bladder (!) as causes of headache. No proper justification for these ideas has yet been attempted, so far as I am aware. Headache is, of course, exceedingly common in menstru- ation, but so it is in eclampsia; yet no one to-day connects the eclamptic headache in any direct way with the condition of the uterus. Toxemia of the puerperium, toxemia of the menstrual period, is a much more plausible, though not a demonstrable, hypothesis. (For further evidence on this point see p. 83.) (0) “ Lithemia ” and “rheumatism ” are also frequently invoked to explain headache. Neither word is defined by those who use them in this connection. ‘‘Lithemia” means constipation and the indigestion of lazy, gluttonous people, conditions which certainly do produce head- ache. (See p. 35.) HEADACHE 30 “Rheumatic headaches” refer usually to the type asseciated with “stiff neck ” and indurations in the bellies of muscles attached to the occiput or the temporal region. (See above, p. 36.) There seems, however, no sufficient reason for continuing the tradi- tion which applies the word “rheumatism” to such lesions. 4. IMPORTANT TESTS The following tests should be made in all puzzling cases: x. Thorough examination of the eyes (including retinoscopy), “the pupil, and the testing of intra-ocular tension (glaucoma). 2. Temperature record (infections). 3. Blood-pressure measurement (nephritis, tumor). 4. Urinalysis (albumin, sugar, acetone). 5- Palpation of the insertion of the nape muscles at the occiput. 6. Examination of the nose and its accessory sinuses. In the history, the following clues should be attended to: (a) Is the headache of paroxysmal occurrence and fixed duration (usually, twelve to twenty-four hours), accompanied by disturbances of vision and great prostration (migraine)? (0) Is the history that of a psychoneurosis? (c) Does the pain recur at precisely the same hour each day? Case 1 A married woman of forty-two consulted me March 17, 1904, for long- standing headaches which had been present, off and on, during the last five years, since an attack of what was called “grip,” followed by deaf- ness and ringing in the left ear. The patient lives in a very malarious part of a specially malarious suburb of Boston, but has never had the disease, so far as she knows. For the past year the headaches have been much more severe, and have come with especial frequency at night, together with a burning sensation over the left side of the head, and to some extent over the entire body, and accompanying this burning sensation she feels chilly, but the temperature has never been taken. ‘he menopause occurred a year ago, and since that time she has noticed that she is getting stouter, that her skin is very dry, harsh, and sallow, with scarcely any perspiration, and that her lips look bluish. Pain and the sense of coldness are often felt in the lower left axilla. Each winter she feels the cold more and more. : Some months ago she noticed edema of the fect and face; at the 4o DIFFERENTIAL DIAGNOSIS present time there is none, but she gets out of breath upon the slightest exertion, and her heart then beats violently, rapidly, and irregularly. Her urine is thick, dark, offensive, and at times its passage is followed by vesical tenesmus. The headache often wakes her in the night, and as soon as she wakes she has to pass water, which gives relief to the head- ache. She thinks she passes more urine at night than in the daytime. She is very irritable, and has much twitching and quivering of the lips. Her only child was born ten years ago, and died within the first year. On examination the hands and lips were of a dark, slaty-blue color, yet quite warm. The face showed a yellow pallor, the total effect being" that often seen under the Cooper Hewitt mercury light, such as is used in automobile garages. The heart was negative, save for a slight sys- tolic murmur at the base. The lungs showed nothing abnormal. The edge of the spleen was easily felt on full inspiration. Its consistency seemed increased. The abdomen was otherwise negative. The tem- perature was 99.2° F. at 5 P.M. The urine, save for high color and other evidences of concentration, showed no abnormality. Discussion.—The possibilities which were first considered in this case included cardiac disease, myxedema, malaria, and another presently to be mentioned. The diagnosis of the attending physician was “some queer kind of heart disease,” but on examination I could find no heart disease, queer or otherwise, although the breathlessness and cyanosis made it natural to search for a cardiac lesion. Myxedema was suggested by the cutaneous changes and the sensi- tiveness to cold, but on cross-questioning neither of these two character- istics was at all well marked, and there were no mental changes, no sub- normal temperature and no special alteration in the physiognomy except as regards the extraordinary coloration before mentioned. It was easily made clear that this cyanosis did not depend upon any disease of the heart or lungs. The enumeration of the red cells showed but 4,180,000, proving that the color of the lips was not due to polycythemia. There was nothing in the symptomatology nor in the gross character- istics of the feces to suggest a cyanosis of intestinal origin, nor did the coloration appear to be of the vasomotor type, so often seen in neurotic and hysteric patients. There was no ebb and flow about it, no varia- tion in the tint from hour to hour, nor from day to day. By rough tests there was no notable deafness and no mastoid tenderness. After excluding the causes above referred to, it was natural ‘to think of methemoglobinemia, such as is often produced by overdose of head- ache powders containing acetanilid. Her attending physician had given her no such powders nor any diug belonging to the group prone to pro- HEADACHE, 4 duce methemoglobinemia, but on questioning the patient I learned the following facts: For the last five years she had been taking headache powders in increasing numbers. Her husband obtained a box of them from the local druggist once or twice a week, and by calculation it appeared that she had averaged too grains a week for some months, great relief being thus obtained for the headache. A drop of her blood soaked into the bibulous paper of the Talqvist hemoglobin scale produced a chocolate-brown stain, quite incomparable with any of the hemoglobin tints of the scale. Spectroscopic examina- tion showed the familiar spectrum of methemoglobin. Outcome.—The patient was ordered at once to stop the headache powders and to take no medicine containing acetanilid or any member of that group. May 3d she reported that her headaches were much less, her sleep and breathing much better, and her sensitiveness to cold much Jess troublesome. She was still weak and pale, but her appetite was much improved, and she had gained eight pounds since March 17th. January 26, 1907, the attending physician writes me: “A year after you saw her the general condition was much better, although she occa- sionally had severe headaches. ‘The color of the blood was improving, but at the time of the last examination which I made, a year after you saw her, blood still showed a tinge of brown.” Diagnosis.—Mcthemoglobinemia. Case 2 A longshoreman of thirty-six was first seen March 8, 1904. The patient has been in the habit of taking three glasses of whisky a day. He had gonorrhea at twenty-six, and chancre twelve years ago, followed by sore throat, a mucous patch, and an eruption. He had typhoid and pneumonia at thirty. Family history good. For a good part of the past five years he has had frontal headache. Last October he began