Moses Maimonides (also known as the
Rambam from his Hebrew acronym; 1135-
1204 AD), the revered headache expert,
was a rabbi, physician, and philosopher
and a prolific author of numerous influential works
including Guide for the Perplexed, Mishneh Torah,
and Medical Aphorisms of Moses. Born in Cordova,
Spain, he lived most of his adult life in Cairo,
Egypt where he became court physician to the
Sultan Saladin. His treatises became influential for
generations of physicians. In November 2008, just
before presenting a lecture at the First
International Headache Summit in Tel-Aviv, Israel,
I made a brief pilgrimage to the tomb of
Maimonides in Tiberias, on the western shore of
the Sea of Galilee (Photo 1).
Maimonides' description of the symptoms and
causes of migraine headaches, which echoes that of
Hippocrates and Galen, is as follows: “
Some people with unilateral headaches called
migraine feel the pain sensation outside the membranes
of the brain whereas others feel the pain
into the depths of the head. The pain in sufferers
of unilateral headaches only extends to the linea
mediana which separates the two halves of the
skull. If it is due to biliary humors, the pain is
burning. If it is due to an excess of humors [whose
vapors ascend to the brain], a sensation of heaviness
is also felt. If the heavy sensation is associated
with a red appearance and warmth, these
excessive humors are sharp. If it is not associated
with redness or warmth, these excessive humors
are without sharpness.1
How many other physician memorial sites are
widely visited? I can think of the site of one other,
who was also a headache expert: Thomas Willis
(1621-1675), who is buried at Westminster Abbey.
Willis, who was Sedleian Chair of Natural
Philosophy at Oxford on recommendation from
King Charles II (be thankful that you don't need
royal recommendations for promotion committees),
first introduced the vascular theory of migraine.
Willis, of course, coined the term “neurology”
(from the Greek “neurologia”) in 1664 and was the
founder of our field as well as a pioneering neuroanatomist
and neuroscientist. (His income, by the
way, was said to be the highest of anyone at
Oxford.) His descriptions of migraine are similar to
ours, including the migraine prodrome, some triggers,
and the following probable first description of a patient with chronic migraine. The subject is
Anne, Countess of Conway, who was also treated
by William Harvey and Robert Boyle:
Some twenty years since, I was sent for to visit a
most noble lady, for above 20 years sick with an
almost continual headache, at first intermitting.
She was of a most beautiful form, and a great wit,
so that she was skilled in the liberal arts, and in all
forms of literature, beyond the condition of her
sex, and as if it were thought too much by nature,
for here to enjoy so great endowment without
some detriment, she was extremely punished with
this disease. Growing well of a feavour before she
was 12 years old, she became obnoxious to pains in
the head, which were wont to arise, sometimes of
their own accord, and more often upon every light
occasion. This sickness being limited to no one
place of the head, troubled her sometimes on one
side, sometimes on the other, and often thorow the
whole encompass of the head.
During the fit (which rarely ended under a day
and a night's space, and often held for two, three
or four days) she was impatient of light, speaking,
noise, or of any motion, sitting upright in her bed,
the chamber made dark, she would talk to no
body, nor take any sleep, or sustinance. At length
about the declination of the fit, she was wont to
lye down with a heavy and disturbed sleep, from
which awakeing she found herself better, and so
by degrees well, and continued indifferently well
till the time of the intermission. Formerly, the fits
came not but occasionally, and seldom under 20
days of a month, but afterwards they came more
often: and lately she was seldom free. Moreover,
upon sundry occasions, or evident causes (such as
the change of the air, or the year, the great aspects
of the sun and moon, violent passions, and errors
in diet) she was more cruelly tormented with
them. But although this distemper, most grievously
afflicting this noble lady, above 20 years (when
I saw her) having pitched its tents near the confines
of the brain, had so long beseiged its regal
tower, yet it had not taken it: for the sick lady,
being free from a vertigo, swimming in the head,
convulsive distempers and any soporiferous symptoms, found the chief faculties of her soul
The biography of Willis by Carl Zimmer, “Soul
Made Flesh: the Discovery of the Brain and How It
Changed the World,” is excellent and available from
online booksellers for a modst cost.
The keynote address of the 2008 Headache Summit
was delivered by Boston University humanities professor,
Nobel laureate, and awardee of the
Congressional Medal of Freedom, Elie Wiesel. He is
the author of 57 books, most prominently Night,
about his experiences in Auschwitz and Buchenwald.
Excerpts from his address were recently published.
Here are some of his comments:
Now, I must tell you, Dr. Mauskop, you kindly
asked me to come and see you for my headaches.
I didn't come because I did not want to embarrass
you, to cause you to have to admit failure,
because nothing has ever helped me. I began having
headaches—I'm speaking to you as a patient—
at age 7. At age 7, I already was taking pills for
headache; everybody in my family was! My mother
had headaches; my father had headaches; my
grandfather had headaches. So I lived with
headaches from my childhood on.
But then something bizarre happened: the day
I entered Auschwitz, the headaches disappeared.
I studied what you told me about pressure, about headaches as the result of pressure. But that
seemed a contradiction. If ever I had pressure, it
was there. In the camp. Every moment was pressure.
But the headaches disappeared.
The moment I arrived at the first orphanage in
France, after Liberation, they came back. The
first doctor I went to I saw for my headaches.
They are still with me. And they are not rare; they
are still frequent. I get up every day with a
headache, and once a week, I have what I call the
“deluxe” version, a real headache. My problem is
if I have to give a lecture that day—and I teach
full time—or that evening, what do I do? If I take
strong pills, I'm afraid it could affect my thought
processes. I try to cope. I didn't come to see you.
I thought, why should I give you pain by realizing
that you cannot help my own? …My headache is
so faithful to me; it's so loyal that it remains present
I got up this morning with a very, very bad
headache. So, I said to my headache, “You won't
win.” I speak to my headache; I personalize it. I
say, “I know who you are, and I know what you
want, and it won't work.” And the pain says to
me, “Let's see, Wiesel.” And so we fight.
… And to this day I have not found a way of
handling my own headache except in my own
fashion, which is to live with it. It hasn't slowed
down my work. I teach full-time, and I am a very
obsessive professor. In some 40 years, I don't
think I've ever given the same course twice. I
want to be the best student in the class. That's
how I learn and grow with the students. And all
that with my constant companion, this headache.
Now maybe once I've finished, you will have a
session and say, “Now what can we do for Elie
Wiesel's headaches?” But don't bother; even if you
were to try, I don't think you could help. But perhaps
you can use my example to encourage your
patients. Patients will come to you and say, “Why
can't you help me?” And you can say, “Look. He
couldn't get cured, and nevertheless he works. He
goes on, functioning, studying, teaching.”
Maybe psychologically I need the headaches to
work? I'm sure some of you have had that idea in mind. Maybe he needs the added challenge—this
extra burden. In that case, why did I have
headaches at age 7? And 8 . . . 9 . . . 10?
Hereditary? Sure. Pressure? No. What pressure?
School pressure? I was a good student.
So do I need these headaches? Personally, I
think not. I think I could work as well without
them. Are they part of me? Are they part of my
psyche? Is my headache part of who I am? If so,
what a terrible analysis—what a terrible definition
of self! Am I my own pain?
So, how might I use even the pain of headache
for the benefit of someone else? How can I do
that? By doing my work, sure. So I go on; I'm a
writer; I'm a teacher; I go around the world trying
to do my best to improve some conditions
here and there, always failing. But it doesn't matter
. . . I will go on trying.
Leave Me Alone?
For centuries, humans have battled and coped with
migraines. As clinicians, we are challenged, as well,
but we all must persist. As Weisel said, “One last
thing to add, something perhaps to tell your patients:
When a person says, ‘Leave me alone, I have a
headache,' it's wrong. Never leave me alone. Never
think that you bother me. I may have the worst
headache in my life, but if someone needs me, I
have no right to say, ‘But I have a headache.' That is
not a sufficient excuse.”
The 2nd International Headache Summit will be in
Tel Aviv April 29 thru May 1: http://headache-summit.
Adapted with permission from the Texas
Neurological Association newsletter, Broca's Area.