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Seven patients who developed a similar headache syndrome are described. They first developed severe, exploding headaches while swimming, and subsequently experienced less severe headaches during physical exertion. They also developed headaches during sexual activity, which were similar to the previous headaches brought on by swimming. Majority of them were women in their thirties or forties. These symptoms were gradually subsided with or without medication after several weeks or months. The possible pathogenesis of this headache syndrome is discussed.
The aim of this work was to study digestive tract function by means of xylose test in patients with attacks of headaches. The investigations were carried out in 14 patients with migraine, 10 with Horton's headache and 1 patient with both these conditions. In patients with migraine or Horton's headache the xylose test was normal in 65% of cases, in the remaining 35% (8 patients, 4 in each group) xylose elimination was abnormal, because it was below 30%. The authors discuss the factors which could influence the abnormal results of xylose test in these patients, since they had no signs of other diseases than the mentioned headaches.
The results of the study of the activity of platelet monoamine oxidase (MAO) in patients with migraine headaches or with 'cluster headaches' are presented. In both types of headaches, MAO activity is lower than in normal subjects. We suggest that the low MAO activity is due to a primary constitutional defect.
Headache in the temporal, frontal and suboccipital regions are described as to case history, findings and differential diagnosis. With due respect to possible further symptoms of dysfunction, the author indicates as principles to treatment: 1. restoration of the continuity of the rows of teeth, and of the occlusal relations; 2. restoration of correct jaw relations; 3. rehabilitation of masticatory muscles.
We present a detailed anterospective inventory on headache which has been developed systematically with several alterations in the course of the experience of several years. It offers the possibility of an almost complete collection of data which can be fed directly into a computer and it appears to be a valuable aid in the training of new co-workers. Some clinical results are discussed on the basis of the inventory.
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Headache is an alarm sympton, whether there is an organic disease (lesional headache) or a perturbation of one of the various functions of the head (functional headache). Lesional headaches follow a sinusitis or an arthrosis, or accompany a "temporal arteritis of Horton". Funstional headaches include several varieties. 1. Trigemellar neuralgia. 2.Vascular algi originating from the basal arteries, the large cerebral venous sinuses or the branches of the external carotid. Among these are: a) headaches due to a dilatation of the internal wall, causing "Horton headache", migraine-like psychosomatic migraine and hormonal migraines (premenstrual, menstrual, menopausal or linked to the use of contraceptive pills); b) headaches caused by an angiospasm of the arteriole, which is the case in exposure to the cold, in traumatic headaches (malfunction of temporomandibular articulation, dry alveolitis), in psychosomatic angiospastic algias and in ethmoidal artery algias preciously described by the author in 1949 (Godin's disease).3. Headaches due to psychic hypertension. 4. Postconcussional psychogenic headaches. 5. Neurotic headaches. The author gives a detailed description of the subjective symptoms in each case, including localisation, from, intensity, duration course and associated phenomenons. This facilitates greatly the differential diagnosis and the choice of complementary examinations. Necessary biological investigations should be performed (e.g. hormonal balance). One should however avoid to increase the number of complementary examination which would only delay treatement and would expose patients to somatisation. Furthermore, in each case drug treatment, periarterial infiltration technics of the temporal, internal frontal, facial, mastoid and occipital arteries are described. The necessity of questioning the patient at lenght and to listen to him to enable him to verbalise conscious conflicts is emphasized. A serious medicopsychlogical examination and a relaxation treatment to reduce anxiety and muscular tension are advised in some cases.
Headache is an alarm symptom, whether there is an organic disease (lesional headache) or a perturbation of one of the various functions of the head (functional headache). Lesional headaches follow a sinusitis or an arthrosis, or accompany a "temporal arteritis of Horton". Functional headaches include several varieties. 1. Trigemellar neuralgia. 2. Vascular algia originating from the basal arteries, the large cerebral venous sinuses or the branches of the external carotid. Among these are: a) headaches due to a dilatation of the internal wall, causing "Horton headache", migrain-like psychosomatic migraine and hormonal migraines (premenstrual, menstrual, menopausal or linked to the use of contraceptive pills); b) headaches caused by an angiospasm of the arteriole, which is the case in exposure to the cold, in traumatic headaches (malfunction of temporomandibular articulation, dry alveolitis), in psychosomatic angiospastic algias and in ethmoidal artery algias previously described by the author in 1949 (Godin's disease). 3. Headaches due to psychic hypertension. 4. Postconcussional psychogenic headaches. 5. Neurotic headaches. The author gives a detailed description of the subjective symptoms in each case, including localisation, form, intensity, duration course and associated phenomenons. This facilitates greatly the differential diagnosis and the choice of complementary examinations. Necessary biological investigations should be performed (e.g. hormonal balance). One should however avoid to increase the number of complementary examinations which would only delay treatment and would expose patients to somatisation. Furthermore, in each case drug treatment, periarterial infiltration technics of the temporal, internal frontal, facial, mastoid and occipital arteries are described. The necessity of questioning the patient at length and to listen to him to enable him to verbalise conscious conflicts is emphasized. A serious medicopsychological examination and a relaxation treatment to reduce anxiety and muscular tension are advised in some cases.
This work is an attempt to find an answer to the question: once arrived at the diagnostic identification of a certain type of idiopathic headache, which treatment should be followed? On the basis of recent researches and experience acquired during ten years' activity of our Headache Unit, a diagnostic identification can be made for migraine (in all its types and evolution stages), cluster headache, tension headache and pure psycogenic headache. Among the most widely used drugs, positive pharmacological results were obtained with: cyproheptadine, pizotifen, cinnarizine, lysergic acid derivatives, histamine, reserpine, clonidine and a barbituric acid derivative. The therapeutic cycles were standardized, for each drug, in the way of administration, dosage and total duration of the treatment. A comparison between the data obtained and the pre-therapeutic situation was made. When repeated, the most efficacious therapeutic cycle was evaluated. According to Pearson's dispersion index, each group of patients improved respresents 16.68% of the expected total results (frequency of attacks reduced to 50%, 25% and 0%): for cyproheptadine, pizotifen, methysergide, histamine, clonidine and allil-propyl-malonylurea, the "p" is less than 0.001; for cinnarizine, less than 0.02. This "a posteriori" analysis does not take into account the placebo control, the "anticipation effect", and the "carry over effect". It cannot therefore be a comparison of efficacy among the various drugs. An evaluation based on "among patients" and "inside patient" method by means of the cross over system, can instead give some useful suggestion about which treatment is to be recommended to patients suffering from recurrent headaches. With regard to migraine sufferers: cinnarizine, cyproheptadine, clonidine, histamine, pizotifen und reserpine. For cluster headaches: cinnarizine, cyproheptadine, clonidine, histamine and reserpine. For tension headaches: cyproheptadine. For pure psychogenic headache: allyl-propyl-malonylurea. For migraine attacks or parossystic crises in the course of ondulating or continuous headaches, positive therapeutic results, statistically significant, were obtained with an association of indomethacin, caffeine and prochlorperazine.
It appears that a uniform "psychosomatic headache" does not exist. This is due to 1. the variety of phenomenology, 2. the variety of causes and 3. the variety of results in the psychodiagnostic and psychotherapeutic field. Analysis of the factors active in headache was attempted in a field study and on the basis of a systematic survey of many years of clinical experience. Within the framework of the concept of multifactorial causation of headaches we found 3 particularly important factors: vasolability, depression and the cervical spine. From the psychodynamic situation disturbing factors appear to be able to produce or maintain headache in this way. Physical examination by itself without taking psychodynamics into account will have to be called just as incomplete as an approach based exclusively on depth psychology alone. The questions on endogeneicity versus exogenicity have to be thought about both from points of phenomenology and individual analysis of the psychodynamic background of every patient, as part of a complex concept of treatment. Headache as an early sign of schizophrenia is rare but should not be forgotten. Among the many factors causing headache it is by no means always clear what is cause and what effect. Often there appears to be interaction which continues in the end autonomously or increases. It has been described on the example of the painspiral in the region of the cervical spine. For diagnosis we try to determine the various pathogenic factors via an anterospective program of examination. This will serve as the basis for our "targetted polypragmasia" i.e. we attempt to influence at one and the same time many of the factors which have been recognized as pathogenic. Drugtherapy apart we favor somatic vegetative stimulation. The results of our field study (strong preponderance of headaches among the non-manual professions together with clinical experience) support our view that in this way we enter an etiologically highly effective circuit. The effectiveness of phsychotherapy lies for the greater number of headache-patients within the zone of initial clearance, less in the direct action on the syndrome of pain. As main therapy psychotherapy has proved effective only in individual cases of predominantly psychogenic headache. We could also discuss the role of neuroleptic sleep cures which soothe psychologically and act also biochemically. No short-cuts and no sound simple prescriptions for the treatment of headache could be given. But the author hopes to have contributed to understanding of a complex field which may result in multi-layered but also clearly defined factors and their more effective therapy.
The controversial relations between migraine and vascular headache on one hand, epilepsy on the other hand are once more discussed: survey of the arguments for a more than fortuitous connexion, taken from literature and general experience. Critical analysis of the personal case material. Discussion of some specific groups of patients with various combinations of both syndromes: long antecedents of headaches, leading up to sporadic epileptic attacks, focal or generalized; clinical seizures under photic stimulation (10% of the cases with chronic headaches without organic lesions); headaches in the latency period of symptomatic epilepsy; cases of seeming transition between the two syndromes; headaches as a substitute, an aura or as a component of the epileptic seizure, with clearly distinctive features between generalized and focal epilepsy: in patients with bilateral EEG paroxysms, headaches are usually diffuse or bilateral, in those with epileptogenic foci, headaches, if consistently localized, are always reported to be homolateral to the focus. Considerations concerning pathogenesis include the familiar hypothesis of hypoxic discharges following migrainous vasoconstriction, as well as secondary vascular headaches induced by focal epileptic activity. Headaches caused by excessive discharges in the sensory representation areas (H. Jackson) must be rare. Whether increased neuronal activity in the hypothalamus may be responsible for the migraine syndrome (Herberg), possibly in connection with biogenic amines, remains in open question.
Of 27 patients with phaeochromocytoma, 20 were subject to headaches as a part of their symptom complex and 7 were not, in spite of the fact that 4 of the latter had experienced other forms of headache at other times. There was no correlation between the proportion of noradrenaline to adrenaline produced by the tumour and the presence or absence of headache or the nature of the headache. Liability to headache appeared to be linked with the rate of change in blood pressure and was not related to absolute values of blood pressure. Two patients experienced a "funny turn" typical of catecholamine release during a spontaneous migraine headache. The migraine headache became pulsatile and severe in one patient but was unaltered in the other. The variable duration and intensity of the headache in different patients can be explained by the pressor and cranial vasoconstrictor effects of the secreted amines which respectively enhance and diminish vascular headache.
It is thus evident that the mechanisms of headache differ widely from one syndrome or symptom complex to another. Both intracranial and extracranial structures may be involved. Knowledge of headache mechanisms is indispensable to the clinician charged with the management of his patient's complaints. Such knowledge should guide the investigations which may be required, and the treatment program to be instituted. As knowledge of headache mechanisms is broadened and our current concepts are altered, we can expect to learn more, not only about the complicated nature of the subject, but also about patients. Future research on headache will almost certainly concentrate on headache mechanisms and will be concerned with molecular mechanisms, immunity and the biochemistry of vascular mediators. That is as it should be, as the pursuits become increasingly focused and scientific. Yet it must also be emphasized that headaches occur, so far as we know, only in man, that they are unique to the human situation, and they cannot be understood without considering the personality, environment, and hopes and aspirations of the individual. In the end, many headaches will be seen to be a problem of inappropriate life adjustment, of poor tempo, a type of conditioned response evoked by the individual's attempts to deal with the vicissitudes of life. This "headache mechanism," so frequently a part of the human condition, will be understood by the perceptive physician as a symptom of his patient's dysfunction, and treated accordingly.