Viewpoints: Migraine: From Maimonides to Weisel

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

Thomas Willis

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 sound enough.

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.

Elie Wiesel

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 always.

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. com/V2/index.php

Adapted with permission from the Texas Neurological Association newsletter, Broca's Area.

1. From “Medical Aphorisms of Moses.” Also see Rosner F. Headache in the writings of Moses Maimonides and other Hebrew Sages. Headache 1993; 33:315-319.
2. From Pearce JMS. Historical aspects of migraine. JNNP 1986; 49:1097-1103; You may also want to read Rengachary SS, et al. The legendary contributions of Thomas Willis (1621-1675): The arterial circle and beyond. J Neurosurg. 2008;109(4):765-75 and Magiorkinis E, et al. Headaches in antiquity and during the early scientific era. J Neurol. 2009;256:1215-1220
3. If you don't have time for the book, you may want to read an extensive review and commentary, Feindel W. Brain. 2004:127:2373–2380)
4. Lagniappe. Wiesel's headache. Headache; 2010; 50: 1087-1088