– Shkenca dhe Jeta –
The following is an example of the people’s health care policy pursued during the People’s Socialist Republic of Albania, published in the magazine Science and Life. It is republished by The Voice of Albania as an historical text from 1978, and cannot be considered our own concrete medical advice.
For the ordinary patient, migraine and headache are more or less synonymous. In fact, however, alongside typical migraine there are also numerous forms of cephalalgia, or headache (from cephalos, meaning “head”), so the similarity between them lies in only one respect: the presence of headache.
Headaches are numerous and highly varied. Thus, for example, there are headaches caused by brain tumours, which are very rare, as well as headaches associated with meningitis; there are severe cephalalgias of a clearly defined nature that disappear following specific treatment; there are specific “cephalic disorders,” the most typical example of which is migraine, which, although generally benign, is nevertheless a serious condition; and there are also cephalalgias arising from psychological tension, most commonly experienced towards the end of the day and resulting simply from fatigue or anxiety. A large number of cephalalgias have been identified. Their causes differ fundamentally and consequently so do their treatment and management.
Migraine
Migraine can sometimes be difficult to diagnose. Repeated examinations and consultations with specialists are often necessary.
At times, migraine may give the impression of being something quite different from a headache. A migraine attack may begin with a sensation of fatigue and physical exhaustion, which often follows an ascending pattern from morning until evening. Curiously, a person suffering from migraine may perceive a bright, more or less coloured light within the visual field, which rapidly expands until it obscures vision; this is known as a “scintillating scotoma.” Once this phenomenon has passed, a headache develops, predominantly affecting one side of the head and accompanied by throbbing of the arteries. The patient may perspire profusely while also trembling and shivering. The patient’s appearance can be alarming: “He looks green,” observers may remark. Dizziness occurs. These episodes of genuine vertigo often culminate in repeated vomiting and, when the stomach is empty, the patient may vomit bile. The patient generally assumes that the entire episode is an attack of the gall bladder, particularly if eggs have previously been eaten. The physician, however, despite these symptoms suggestive of digestive disturbance, recognises that the patient is suffering from migraine.
Whether or not it assumes this characteristic appearance of digestive disturbance, which is by no means among its most common manifestations, migraine is a frequent disorder, affecting one person in 10 and perhaps even one person in five. Diagnosis may sometimes be complicated by the severity of the digestive symptoms, but a unilateral headache, often preceded by “scintillating scotomas,” is highly suggestive.
To determine whether the condition is indeed migraine, the physician will often investigate the patient’s family history in search of an ancestor who may have suffered from the disorder. In 75 per cent of cases, a grandmother or aunt can be identified who suffered from the same complaint, which affects women more frequently. This suggests the existence of a genetic predisposition to migraine. Finally, the physician’s enquiries also extend to the earliest years of adolescence in order to identify manifestations of migraine dating back 20 years in most cases, or even to the period before puberty. Migraine also occurs in children, particularly those of school age.
How can migraine be defined?
It is primarily a headache accompanied by a misleading array of symptoms, including nausea, dizziness and vomiting. Migraine is distinguished by its particular symptoms, by its high frequency in comparison with other forms of cephalalgia and by the chronic phases of its development.
Let us consider the different stages that characterise a migraine attack: there is an initial phase, involving a “scintillating scotoma” in the visual field and pallor of the face, caused by a spasm of the cerebral arteries and an inadequate supply of oxygen to the brain. This is followed by a cephalalgic phase, in which the headache is caused by dilation of the arteries. Finally, if the migraine attack persists, there may be a phase characterised by cerebral oedema, meaning that the cerebral tissues become saturated with fluid. This is the classical description of a migraine attack. The role of the cerebral blood vessels in the mechanism of migraine is immediately apparent and of fundamental importance. The pain is, in fact, directly associated with dilation of the arteries of the head. This indicates that medical treatment of an acute migraine attack requires ergotamine tartrate, a substance known for its vasoconstrictive effects and one that is also highly effective against pain when taken at the onset of an attack. Combined with antiemetic drugs to counter vomiting and antihistamines to suppress allergic reactions, this treatment arrests the attack within half an hour in most cases.
What has been described, however, concerns the treatment of migraine during the acute phase of an attack: such treatment combats the symptoms of the disease rather than its causes. The causes themselves remain relatively poorly understood. They are undoubtedly far more complex.
According to some researchers, one migraine in four is also of allergic origin, in a manner comparable to asthma or urticaria. In some individuals, attacks frequently appear to be triggered by difficulty in digesting foods such as chocolate, eggs, strawberries or melon. This is observed particularly in children. Keeping a food diary often enables parents to identify the foods to which their child is allergic — milk is frequently implicated — and to eliminate the offending food from the diet. This results in a reduction in the number of attacks. Migraine therefore appears, in some cases, to manifest itself as an allergic disorder, to the extent that treatment of an attack may also include antihistamines. Histamine is a substance produced within the body and released during allergic reactions.
Other factors also play a significant role in precipitating migraine attacks. In women, hormonal changes associated with the menstrual cycle exert an influence. Attacks are more frequent during menstruation. By contrast, there is a marked reduction in attacks during pregnancy and lactation. Finally, migraine ceases permanently after menstruation has ended. This has led physicians to suggest that the menopause remains the best treatment for migraine.
Climate must also be taken into consideration. Some studies have found that, in many cases, a warm southerly wind preceding winter serves as a warning of an impending attack for migraine sufferers.
Whatever the circumstances, however, patients may consult physicians believing that they already understand the origin of the disease, know everything there is to know about it and have already taken all the necessary measures. The physician must rely on sound scientific explanations to persuade the patient to undergo appropriate and systematic treatment.
One further important matter must be noted. This certainly does not apply to all migraine sufferers, but in some cases an unstable neuropsychological equilibrium influences the occurrence of migraine attacks. The psychological instability of certain patients appears, above all other factors, to aggravate the condition, if it is not itself the original cause that precipitates the onset of migraine.
It must be emphasised that migraine is a genuine illness, not a pretence or an excuse employed by someone who does not wish to work, or by a pupil who does not wish to attend school because an essay or written assignment is due, and so forth.
Research on migraine differs principally with regard to methods of treatment and medication. Thus, for example, hormonal treatments, allergic desensitisation, spa therapy and psychotherapy are recommended. All these forms of treatment are justified by the frequency of the condition: 15 per cent of headaches, or cases of cephalalgia, are migraines. The economic costs of such a disorder are considerable. Migraine causes a substantial loss of working days, since an attack that is not treated with the necessary medication may last between 24 and 48 hours.
Other Headaches
What can be said about other headaches that are not migraines? Some forms of cephalalgia originate in structures of the head and neck: the skull, face or neck. These include specifically defined forms such as temporal arteritis or Horton’s disease, caused by a highly distinctive lesion of the temporal artery, which becomes hardened and painful; or cephalalgias originating within the ear, nose and throat region, centred on the ears or nose, as in sinusitis, or arising in the pharyngeal region or from the teeth themselves. Disorders of the eyes may likewise cause headaches.
Among the local causes of headache, however, one of the most frequent is arthrosis of the vertebrae at the nape of the neck, known as the cervical vertebrae, which manifests itself as a form of degeneration of these vertebrae. This common rheumatological disorder often causes considerable pain: elderly people may believe that it is responsible for all their ailments, particularly their headaches, apathy or loss of vitality. Arthrosis affecting the uppermost cervical vertebrae, situated immediately below the occipital region of the head, may directly irritate the upper roots of the spinal nerves and consequently cause cephalalgia. Such cases, however, constitute only a minority. More commonly, the affected vertebrae are situated lower down and anatomical studies of this region have demonstrated that the nerve roots are not affected in such cases. Are we therefore dealing with imaginary illness?
Some scientists believe that changes occur in the vertebral arteries: atheromatous plaques developing in this region may cause cephalalgia by producing an inadequate supply of oxygen, or cerebral hypoxia. Nevertheless, it cannot be excluded that, in these forms of cephalalgia, a psychological component is also involved, including the effects of ageing, melancholy and similar factors.
Cephalalgias whose neuralgic centre lies in the nape of the neck, also described as Atlas syndromes by analogy with the giant of mythology who bore the world upon his shoulders, involve pain in the muscles of the nape. The pain may become so severe that the individual feels unable to support the head any longer and compelled to lie down. These forms of cephalalgia, however, also tend to have a predominantly psychological origin.
Accurately diagnosing the causes of cephalalgia is extremely difficult, and specialised examinations are often necessary. These investigations sometimes yield no conclusion, whereas in other cases they reveal that the cephalalgia is a consequence of another, more general disorder. Thus, for example, cephalalgia may occur in people with heart disease, in those with an abnormally high number of red blood cells or in individuals suffering from hypertension.
Cephalalgia and Hypertension
Hypertension, which is an elevation of arterial blood pressure, approximately 160/90 mmHg, has also been recognised as a cause of headache, whether in the form of persistent headaches or headaches occurring during a hypertensive episode.
Severe hypertension undoubtedly causes intense and almost daily cephalalgia directly. Characteristically, these headaches occur during the final part of the night, before waking, and diminish during the morning. Moderate hypertension, however, which is more common, is not a direct cause of cephalalgia; this has been demonstrated. In such cases, it is instead thought that a particular nervous disposition among people with hypertension may underlie both the cephalalgia and the hypertension itself. No direct relationship between the two has been established.
Among the various types of headache discussed above, some originate in the nose, the ocular region or the neck, while others are consequences of another general disorder, such as cardiovascular disease. None of these forms of cephalalgia, however, originates in damage to the brain itself. Nevertheless, this possibility cannot be entirely excluded; scientists have therefore considered whether lesions of the brain might also cause cephalalgia.
Curiously, the brain, the centre of our nervous system, is for the most part an insensitive organ, incapable of perceiving pain: “It can be examined, cut, burned, frozen or fragmented without causing pain.” It is precisely this characteristic that permits remarkable neurosurgical procedures to be performed on fully conscious patients without general anaesthesia, using only superficial local anaesthesia. In fact, only the skull, the blood vessels, certain meningeal coverings of the brain and some cranial nerves are sensitive to pain.
(Translated by The Voice of Albania from the Albanian original: Shkenca dhe Jeta: Revistë tekniko-shkencore, No. 1, 1978, pp. 35-37.)
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