A history of non-drug treatment in headache, particularly - Brain

BRAINA JOURNAL OF NEUROLOGY

OCCASIONAL PAPER

A history of non-drug treatment in headache,particularly migrainePeter J. Koehler1 and Christopher J. Boes2

1 Department of Neurology, Atrium Medical Centre, Heerlen, The Netherlands

2 Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA

Correspondence to: Dr P. J. Koehler,

Department of Neurology,

Atrium Medical Centre, PO Box 4446,

6401 CX Heerlen, The Netherlands

E-mail: [email protected]

Although new invasive procedures for the treatment of migraine have evolved during the past decades, the application of

invasive procedures for this indication is not new. In this review, the history of non-drug treatments for migraine is discussed.

Historical texts by physicians known to have written on headache and migraine (hemicrania), well-known books by physicians

from the main historical periods up to 1900 and mainstream 20th century neurology handbooks were analysed. A large number

of treatments have been tried, based on contemporaneous pathophysiological models that were not only applied to headache,

but to medicine in general. Invasive procedures have been used for the more severe types of headache. Many treatments were

based on ancient humoral theories up to the early 19th century. A new kind of invasive procedure appeared on the physician’s

palette in the 19th and 20th century, following the development of new ideas that were based on solid pathophysiology, after

the introduction of scientific method into medicine. After its introduction in the mid-18th century, medical electricity became

even more popular for the treatment of migraine following the discovery of vasomotor nerves in the mid-19th century, but at the

end of that century a more critical attitude appeared. The discovery of the lumbar puncture (1892) and roentgenogram (1895)

and increased knowledge of intracranial pressure led to a new series of invasive procedures for therapy-resistant migraine in the

early 20th century. Vasospastic theories of migraine led to surgical procedures on the sympathetic nerves. Following the

experiments by Graham and Wolff in the 1930s that emphasized the vasodilatation concept of migraine, sympathicolytic

procedures again became popular, including vessel ligation of the carotid and middle meningeal arteries. The influence of

suggestion and psychological phenomena recognized at the end of the 19th century probably played an important role in

many of the procedures applied. These placebo effects, generally more powerful in invasive treatments, are discussed against

the background of present-day invasive treatments for headache, where they are still a matter of concern.

Keywords: headache; migraine; history of medicine; non-drug treatment; placebo effect

IntroductionPharmacotherapy, the treatment of disease by the administration

of drugs, is presently the principal treatment for headache and

migraine and is as old as recorded history (Weatherall, 1997,

p. 915). During the past few years, several non-drug treatments

have been applied for pharmacoresistant headache, including deep

brain stimulation (hypothalamus for cluster headache), occipital

nerve stimulation (chronic migraine and cluster headache), nucleus

caudalis dorsal root entry zone surgery (post-herpetic neuralgia of

the trigeminal territory), patent foramen ovale procedures and

transcranial magnetic stimulation (both for migraine). In most

doi:10.1093/brain/awq170 Brain 2010: 133; 2489–2500 | 2489

Received January 31, 2010. Revised May 16, 2010. Accepted May 17, 2010. Advance Access publication July 17, 2010

� The Author (2010). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.

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historical reviews of headache, particularly of the last two centu-

ries, drug treatments are discussed. The aim of the present paper

is to determine which non-drug treatments have been applied

for headache and migraine in the past and what lessons can be

learned from comparing these methods and their indications, on

the one hand, with recently applied therapeutic methods on the

other.

MethodsHistorical texts by physicians known to have written on headache and

migraine (hemicrania), as well as well-known books by physicians from

the main historical periods up to 1900 were analysed. In order to

secure a representative list of books from this period, commonly

known medical and neurological books in English, German, French

and Latin were selected from two standard books, Garrison’s History

of Neurology and the ‘Diseases of the nervous system’ section in

Morton’s Medical Bibliography (McHenry, 1969; Norman, 1991).

Additionally, mainstream neurological handbooks of the 20th century

have been studied to review contemporary non-drug treatments. We

defined ‘non-drug treatments’ as treatments that were not based on

the administration of plant or other chemical substances that are

applied in medicine (by mouth, skin, rectum or parenteral). We

chose to start in the Hippocratic period, when naturally observable

phenomena instead of magical explanations were held responsible

for diseases and omitted prehistorical, Egyptian and Babylonian medi-

cine. We confined ourselves to the western tradition, omitting Indian

and Chinese medicine. Acupuncture was omitted, as it would be a

study on its own and was rarely discussed in the sources that were

consulted.

Results and discussionTable 1 provides an overview of the procedures applied. Up to the

mid-19th century, a clear distinction between headache and mi-

graine, at least with respect to treatment, was not often possible

and therefore we chose to report the treatment of headache in

general, including migraine, in that period. After the final shift

from humoral to solid pathophysiological models and a positivistic

approach of medicine in the first part of the 19th century, mi-

graine became more clearly distinguished from other types of

headache. As dietetics, massage and gymnastics were advised

throughout the periods under discussion; they were considered

general methods and are not discussed in detail.

Headache treatment in the traditionalperiod (humoral medicine)The withdrawal of body fluids in order to restore the right balance

(eukrasis) should be considered from the perspective of humoral

medicine in which a balance of the four humours (blood, phlegm

and yellow and black bile) was believed to determine health and

disease. If drug treatments and other measures that sufficed in

many instances failed, humoral substances could be withdrawn

by several methods.

BloodlettingWith respect to headache, knowledge from the Greek-Roman

period can best be demonstrated by Aretaeus’ work (first part of

second century CE), which may be considered a basis for know-

ledge of the past twenty centuries. His books follow the

well-known sequence a capite ad calcem (from head to heel)

and his therapies for headache were referred to for centuries.

Bloodletting was a regular treatment for many diseases, including

headache. If the usual treatment did not succeed, not only was

blood taken from veins in the arm, but a vein or even an artery of

the forehead was incised. The treatments became more invasive if

previous ones were ineffective. If subsequent cupping was unsuc-

cessful, he bled sufferers from the nose:

‘. . . take the shaft of a thick goose feather, scrape off a bit from

the outer layer and make notches into the fibres so that it

Table 1 Non-drug treatments since the Hippocratic period

Traditional period:

Bloodletting

Arm veins

Head veins

Head arteries

Opposite side of the head (Byzantine period)

Bleeding from nose

Leeches

Withdrawing other bodily fluids by

Cupping

Blistering

More invasive procedures

Cauterization

Incisional garlic

Trepanation

Various

Oil in the ear

Warm baths, water

Binding dead mole on the head

Magnets

Early electrical treatment

(Dietetics, gymnastics, massage)

19th and 20th centuries:

Electricity

To the head

To the sympathetic nerves

Physical treatments:

Arterial compression

Vibration therapy

Hydrotherapy

(Dietetics, gymnastics, massage)

Psychotherapy

Radiotherapy [pituitary (Bromley, 1944)]

Surgical procedures

Ear, nose and throat procedures

Lumbar puncture (intracranial pressure)

Sympathectomy

Blood vessel ligation (carotid and middle meningeal)

Afferent sensory surgery (mainly trigeminal)

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results in teeth like on a saw. Subsequently, push the shaft

inside the nose up to the ethmoid bones, move it with both

hands in order to create scratches at that site. In this way, a lot

of blood will be discharged in a short time, as many small veins

end there, and the site is soft and easy to injure’ (Aretaeus,

1958; Koehler and Van de Wiel, 2001).

During the subsequent centuries, not much changed.

Three physicians from the Byzantine period will briefly be

mentioned here, notably Oribasius of Pergamon, Alexander of

Tralles and Paul of Aegina (Figure 1). Oribasius (325–403), the

personal physician of Emperor Julianus Apostata, advised purging

and bloodletting in hemicrania (Oribase, 1873). Alexander of

Tralles (525–605), who had a great reputation in Rome, Spain,

Gaul and Italy, advised bloodletting from the side opposite to

the side of the headache (Tralles, 1878). Paul of Aegina (625–

690) the famous obstetrician from the Greek island of Aegina,

advised, among other treatments, to open the veins of the nose

(Aegineta, 1844).

One of the ways by which the Greek–Roman medical tradition

returned to Europe, in particular for the 11th century medical

schools of southern Italy (including the Salerno), was through

Arabic medicine. An important physician and polymath during

this period was Maimonides (1135–1204); born in Cordoba,

but expelled from Spain, he became Court Physician in

Morocco, and then moved to Cairo where he became Royal

Physician. Among his ten medical treatises, the 1500 medical aph-

orisms, mainly based on Greek sources, contain various references

to the treatment of headache. In severe cases of migraine he

advised bloodletting from ‘the pulsating arteries behind the

ears’. If no benefit was seen after this procedure, he assumed

that ‘the vapours which produce the illness rise to the brain

through other pulsating arteries which are not visible on the sur-

face substance, and which rise to the base of the brain’ (Rosner,

1993).

For hemicrania the ‘Dutch Hippocrates’ Forestus (1521–97)

advised leeches among other treatments (Foreest, 1653).

Thomas Willis (1621–75) distinguished three types of habitual

headache, including continuous headache, intermittent headache

and intermittent headache with vague and uncertain attacks (Isler,

1986). Accidental headaches often disappeared spontaneously

and, if not, could be cured by phlebotomy (bloodletting); arter-

iotomy was also mentioned (Willis, 1674, p. 264). In ‘obstinate

headaches, the Scottish physician Robert Whytt (1714–66) advised

a large evacuation from the vessels of the nose’ (Whytt, 1765,

p. 513). Headaches from suppression of the menses needed

‘bleeding, especially at the ancles’ (Whytt, 1765, p. 515).

Sometimes leeches were applied to the temples, and for violent

headaches an artery at the headache site needed to be opened in

some cases. In plethoric patients, blood was taken from the jugu-

lar vein.

Withdrawing other bodily fluids

Cupping and blistering

By placing heated glass tubes on the skin, blisters were drawn and

this again was thought to restore the balance of the humours. In

the Hippocratic works (ca. 460–370 BCE), a few references are

found on what to do in cases of headache. In most descriptions

Figure 1 Title pages of 19th century translations of the works by A. Oribasius, B. Alexander of Tralles and C. Paul of Aegina (Aegineta,

1844; Oribase, 1873; Tralles, 1878).

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the accompanying signs point to symptomatic causes, but other

types of headache are also described:

‘Pour la douleur intense de la tete, quelle que soit celle des

parties superieures qui souffre, appliquez une ventouse’

(Aphorism. 59; Littre, 1861).

[For intense pain of the head, whatever of the upper parts that

is suffering, apply cupping.]

‘Hippokrates’ warned against invasive procedures for benign types

of headache.

‘Il faut savoir reconnaıtre les cephalalgies que proviennent des

exercices du corps, des courses, des marches, des chasses ou de

toute autre fatigue inopportune ou des exces veneriens, . . . les

douleurs intenses dont on ne peut pas triompher. Dans aucun

de ces cas il ne faut purger . . . ’ (Littre, 1840).

[One should recognize headaches that originate from physical

exercises, running, walking, hunting or any other inconvenient

fatigue or venereal excess, . . . intense pains which can not be

overcome. In none of these cases one has to purge. . .]

Aretaeus likewise advised cupping if bloodletting from the arm

or forehead was not successful. His work on headache was still

referred to in the 17th century, for example by the Amsterdam

physician Nicolaas Tulp (1593–1674, depicted in Rembrandt’s

well-known ‘Anatomical Lesson’; Koehler, 1993). In Tulp’s book

we find the case of a carpenter’s wife suffering from headache for

a considerable period. It was accompanied by a warm feeling as-

cending from foot to head and vice versa to the big toe. Tulp

ordered a cup to be set, inducing a sore, by which he believed a

volatile spirit could drain from the body and the patient soon re-

covered. Johann Jakob Wepfer (1620–95) included the shaving of

the whole skull and application of cantharides plasters all over it,

but not for longer than eight hours, as it could cause dysuria (Isler,

1985). Apparently, cantharides not only caused blisters but were

also absorbed.

In Thomas Sydenham’s work (1624–89), no discussion on

headache or hemicrania was found (Sydenham, 1685; 1848).

Herman Boerhaave (1668–1738) did not write much on

headache and just referred to the work of Wepfer and Willis

(Koehler and Bruyn, 1994), but in the work of his Dutch pupil,

Gerard van Swieten (1700–72), we find an accurate description of

what we now recognize as cluster headache, in a chapter on

intermittent fever! Several treatments were tried, including

bloodletting, anti-inflammatory purges, cups to the neck and

blistering plasters, but all were in vain. Finally he applied quinine

(Isler, 1993). Whytt distinguished headache of the whole

head, one side or just one eye. ‘They generally return once

a-day, nearly at the same hour, and as regularly as the fit of a

quotidian ague. In some cases, they are attended with a visible

swelling, not only of the affected eye, but also of that side of the

forehead’, again complaints that could be interpreted as cluster

headache (Whytt, 1765, p. 305). Headaches in sympathy with

the stomach were treated by induced vomiting. For other head-

aches ‘the properest remedies are blisters applied to the head

or legs’.

More invasive procedures

Cauterization

If none of the treatments mentioned above gave relief, Aretaeus

finally applied the red hot iron:

‘Consequently, you have to shave off the hair (which yet on its

own is good for the head) and cauterize superficially down to

the muscles. If you wish to cauterize down to the bone, carry it

out at a site where there are no muscles. For if you burn mus-

cles, you will provoke cramps. Some physicians incise down to

the bone on the forehead along the border of the hair. They

abrade or chisel the bone down to the diploe and let flesh grow

over the place. Others perforate the bone down to the menin-

ges. These are hazardous treatments. You have to apply them

when the headache persists after all that has been done; the

patient keeps courage and the body is vigorous’ (Aretaeus,

1958; Koehler and Van de Wiel, 2001).

Abulcasis (936–1013), who was born in the Cordoba area

(Spain) and became surgeon to King Al-Hakam II of Spain, also

applied the red hot iron, which was a popular method then. If this

did not succeed, he advised to take garlic, peel and cut it at the

two ends, make an incision at the temples with a large scalpel and

make space underneath the skin enough to completely hide the

garlic (Abulcasis, 1861). Blistering plasters and cauterization were

still applied by Claude Pouteau (1725–75), a French surgeon at

the Hotel Dieu hospital of Lyon, as described in his Melanges de

chirurgie (Pouteau, 1760).

‘N’eut-il pas ete plus expedient de donner une issue a cette

humeur, en appliquant sur la tete des vesicatoires, ou en ouvr-

ant un cautere?’

[Wouldn’t it be more expedient to allow the humour to issue

forth, by applying a blister to the head, or applying

cauterization?]

Trepanation

The ‘Dutch Hippocrates’ Forestus generally advised just to help

nature, but in an incurable case he ultimately applied the trepan

and found a ‘black worm’ on the dura (possibly a chronic subdural

haematoma). Willis applied several pharmacological treatments

partly fitting into his iatrochemical theories on headache

(Koehler, 2008), but if this ‘ars medica’ was not of any help,

‘chirugia’ should be applied, in the first place ‘remedia topica’ or

topical treatments (Willis, 1674, p. 274). He mentioned that ‘cal-

varia [sic] apertio a multis praedicata sed raro aut nunquam ten-

tata’, or that the opening of the skull is often advised but rarely

applied at the time (Willis, 1674, p. 276), unless evident local

disease is observed. This is in accordance with Arnott et al.

(2003), who, in their book on trepanation, reported only a few

cases of trepanation for intolerable headache in western medicine,

including a case that appeared to be due to an infection, and

several traditions of trepanations for headache following skull

injury are mentioned. It was stated that ‘migraine and tension

headaches are not among the reasons for recorded trepanations,


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though surprisingly trepanning has been known to relieve such

headaches’ (Martin, 2003).

Various other methodsOribasius, mentioned above, advised the injection of soft oil into

the ear (Oribase, 1873). An interesting treatment for headache

was that recommended by the 10th century astronomer and phys-

ician Ali ibn Isa (ca. 940–1010 CE), who recommended binding a

dead mole to the head (Ali ibn Isa and Wood, 1936). If diseases of

the head occur because of a faulty warm constitution, Maimonides

advised bathing in comfortable warm sweet water, because it

dissolved the sharp vapours that rose to the head and improved

the body disposition. If headache was localized, it was most ap-

propriate to apply massage with oil of roses (Rosner, 1993).

In Samuel-Auguste Tissot’s (1728–97) influential Traite des nerfs

we find an interesting case of migraine aura: an officer in Austrian

service, aged 32 years:

‘Since the age of nine years . . . I have a migraine . . . It begins in

the eyes; at the most unexpected moments, I suddenly see un-

clear, but more on one side than on the other, like a person

who has looked in the sun. This lasts approximately ten minutes;

subsequently an arm and a leg on the same side fall asleep, one

day on one side and then on the other. . . . during this time I

experience quite some trouble to talk. This lasts about half an

hour; subsequently the headache starts, but only at the temples,

where it remains for seven or eight hours very severe: if I am

able to vomit, it provides relief. The migraine may attack me in

every season and at every hour; bleeding only gives little re-

lief. . .’ (Tissot, 1813, p.103–4, Engl. transl. in Koehler, 2005).

Next to bloodletting, Tissot applied the magnetic bar, but rea-

lized that with respect to the attacks there is ‘scarcely anything to

be done . . . . Baths to the legs, enemas, applications to the fore-

head, do no good and only worry the patient’.

Electricity

Early applications for headache

It was not until the middle of the 18th century that scientists

became aware of the electric nature of the benumbing effect of

certain fish. This effect had, however, been known for some time

e.g. by the Court Physician of Emperor Claudius, Scribonius

Largus, who recognized the effects of the torpedo’s discharges

in the first century CE, recommending it for gout and headache

(Scribonius, 1983). The electric eel that was found in the northern

parts of South America gave off more powerful shocks (up to

600 V) than European and African fish. The conscious application

of electricity was introduced into medicine around the middle of

the 18th century. In one of the letters in the Treatises of the

Haarlem Society of Sciences we find the description of the effects

of the eel (Van der Lott, 1762) (Figure 2):

When a slave complains of a bad headache, he has them put

one of their hands on their head and the other on the fish, and

they thereby will be helped immediately, without exception

(Koehler et al., 2009).

Dutch scientists had experienced the effects of the Leyden jar in

1745 (with Pieter van Musschenbroek, 1692–1761) and, while

working in the Dutch West Indies in the 1750s, they noted the

resemblance between the benumbing effect of fish and the effect

of the Leyden jar (Koehler et al., 2009). Electricity from these fish,

but more often electrical machines, became widely applied for

headache and other afflictions. In a book on medical electricity

we read about a man who experienced intolerable pain above

one of the eyes. He was relieved after drawing sparks from that

site for 15 min (Paets van Troostwijk and Krayenhoff, 1788)

(Figure 3).

The French physician Pierre Bertholon (1742–1800), friend of

Benjamin Franklin (1706–90), was among the many physicians

at the time who applied electricity.

Figure 2 Title page of one of the volumes of the Treatises

published by the Dutch Society of Sciences (Haarlem), in which

the electric shocks of the eels of South America for the treatment

of headache are mentioned. The shocks were recognized as

electric because they resembled the effects of the Leyden jar

(Hollandsche Maatschappye, 1778).


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‘. . . sometimes cephalalgia, migraine, cephalea demand for its

curing a negative electricity; because that condition depends on

a too great influence of nervous fluid on the head. I have cured

myself several times from various headaches by applying nega-

tive electricity, mainly directed to the temporal region’

(Bertholon, 1780; transl. PK).

Electricity in the 19th century: migraine andvasomotor theories

In the middle of the 19th century, the scientific method finally

conquered medicine and humoral pathology was largely dis-

appearing. Experimental physiology became an important source

for new medical knowledge. The function of the vasomotor nerves

was discovered by Claude Bernard (1813–78) and Charles Edouard

Brown-Sequard (1817–94) (Bernard, 1852; Brown-Sequard, 1852;

Laporte, 1996) in the 1850s (some consider it a rediscovery, as

these nerves were exactly mapped by Lower and Willis; they

observed and explained their function in the 17th century; see

Spillane, 1981, p. 92). In the subsequent years a debate arose

on whether migraine was a sympathicolytic or sympathicotonic

affliction; the first theory was defended by Brown-Sequard, the

latter was adhered to by the Berlin physiologist Emil du

Bois-Reymond (1818–96), a migraine sufferer himself (Koehler,

1995). Brown-Sequard was supported by several other physicians,

including Mollendorff, who referred to him and used the term

‘angioparalytic’ migraine (Mollendorff, 1867).

The discoveries gave a new impulse to electric treatment that

remained popular for several decades. Rudolf Lewandowski men-

tioned it in his book Elektrodiagnostik und Elektrotherapie

einschließlich der physikalischen Propadeutik (Lewandowski,

1887) (Figure 4A); and Elizabeth Garrett Anderson (1836–1917),

an astonishing woman who became England’s first female phys-

ician in 1870 following medical studies in Paris, advised it in her

doctoral thesis, Sur la migraine (Figure 4B).

She wrote: ‘There are reasons to suppose that in migraine, as

well as in other cases of severe and recurrent pain, the central

lesion consists of imperfect nutrition of nervous tissues. The im-

mediate result of it is a too rapid discharge of electricity inherent

to nervous molecules’. She believed that Voltaic electricity, next to

air and exercise, was the most effective treatment (Garrett, 1870;

a translation of her thesis can be found in Wilkinson and Isler,

1999). The Berlin neurologist (and temporarily professor of

pharmacology in Greifswald) Albert Eulenburg (1840–1917) was

positive about the effects of electricity on migraine. It was applied

directly to the head or to the sympathetic ganglia in the neck,

distinguishing the sympathicotonic and neuroparalytic forms of

migraine from each other, as each required a special application

(Eulenburg, 1878).

The vasomotor theories and resulting therapies reached the

other side of the Atlantic, as shown in William Hammond’s

(1828–1900) textbook (Hammond, 1889). He mentioned the ocu-

lopupillary and vasomotor troubles leading to a dilated pupil

(angiospastic) or, on the contrary, to a constricted pupil ‘and the

upper eyelid droops’, calling it angioparalytic hemicrania. He

advised ‘galvanization of the great sympathetic’ with different

procedures for the angiospastic and the angioparalytic form of

migraine (Hammond, 1889, p. 880). Hammond referred to various

European physicians with experience in electrical therapy, includ-

ing J. Benedict, Rosenthal and Frommhold, who advised faradic

electricity (Frommhold, 1868). Hammond also advised that

Figure 3 Title page of and picture from a book on medical electricity in which headache cases are also described (Paets van Troostwijk

and Krayenhoff, 1788).


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galvanism should be applied between attacks. Electricity was also

mentioned by Charles Loomis Dana (1852–1935) in his textbook.

‘The daily use of a strong galvanic current 4–8 mA (8–10 cells) for

10 min is useful’ as constitutional treatment, and for the attacks he

suggested: ‘Locally galvanic currents are sometimes helpful, and so

are static sparks’ (Dana, 1892).

At the end of the century, several monographs on migraine

were written, including the one by the German physician Paul

Mobius (1853–1907), who was more critical about the effects of

electricity. He reviewed physical treatments, including water ther-

apy, massage and electrotherapy (galvanization of the sympathet-

ic, faradization of the head, the electrical bath), being quite clear

on the effects:

‘There is no other way out, here as with the miracles of mas-

sage, it concerns suggestion. I have occasionally pointed to the

fact that in mild migraine attacks, psychic influences are import-

ant. Therefore, it is obvious that in such type of attack, electric

manipulations will bring ‘immediate well-being’, in particular if it

is carried out by an appropriate personality’ (Mobius, 1894,

transl. by PK).

William Gowers (1845–1915) provided more critical opinions on

electric treatments, including ‘sedative liniments of belladonna,

aconite, etc., or simple counter-irritation by a mustard plaster to

the nape of neck’ in his 1888 Manual. He was not enthusiastic

about electricity, which ‘is not often of service. . . . The voltaic cur-

rent passed through the head occasionally gives transient, but

rarely permanent, relief’. The value of repeated galvanization of

the sympathetic as ‘recommended in Germany . . . is very doubtful’

(Gowers, 1888). Likewise, William Osler (1849–1919) in his

Principles and Practice of Medicine (1892) wrote that ‘electricity

does not appear to be of much service’ (Osler, 1892). In France,

Jules Dejerine (1849–1917) did not provide information on

treatment of migraine as would be expected from the title of his

Semiologie (‘Symptomatology’) (Dejerine, 1914), and although

migraine and electrotherapy were discussed in Pierre Marie’s

(1853–1940) 1911 Pratique Neurologique, the latter was not par-

ticularly mentioned for the treatment of migraine. It was advised

for facial neuralgia amongst other indications (Marie, 1911).

Eduard Flatau (1868–1932) commented that he had never been

convinced of its efficacy during the attack or with respect to its

prophylaxis (Flatau, 1914).

Physical treatments: arterialcompression, vibration therapy andhydrotherapyThe vasomotor theories not only led to electrical treatments but

also arterial compression. Mollendorff (1867) noted that

‘[i]f during a hemicranial attack the common carotid artery on

the painful side is compressed at the level of the thyroid cartil-

age, so much that the pulse of the temporal artery starts to

disappear, the head pain wears off as if by magic. . . . the

other way round, the pain, if not yet reached its full climax,

increases by compression of the carotid artery on the other

side . . .’ (Mollendorff, 1867; transl. PK)

Carotid compression was not completely new, as it had been

applied previously, in 1786, to a young lady with the intention to

‘intercept a considerable part of. . . [the] violent impulse of blood

into the brain’ during paroxysmal attacks of various ‘nervous

symptoms’, including headache, by the English physician Caleb

Hillier Parry (1755–1822) (he published on it in 1788 and 1811,

see Parry, 1811, p. 89–95). Combined compression of the carotid

artery and vagus nerve was advised by Romberg and Schroeder

Figure 4 (A) The hydroelectric bath was used amongst others for headache by Rudolf Lewandowski (Lewandowski, 1887). (B) Title page

of Garrett Anderson’s thesis; she also advised electrical therapy (Garrett, 1870).


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van der Kolk (Liveing, 1873, p. 471), and Hammond (1889,

p. 880) recommended carotid compression during the attack,

but Flatau (1914) mentioned that carotid compression was

hardly applied anymore.

At the end of the 19th century, vibration therapy was used by

Jean-Martin Charcot (1825–93) and later by his pupil Georges

Gilles de la Tourette (1857–1904) for Parkinson’s disease, after it

had been noticed that journeys in post coaches and trains could

relieve the symptoms. Special vibrating chairs were designed for

this purpose (Goetz, 2009). It was also applied for headache and

migraine. In a book on vibration therapy of the period, we find

that ‘hemicranial headache is best treated with the brush, applied

very lightly on the scalp, and moved from below upwards and

from before backwards, a few times in an orderly manner’

(Mortimer Granville, 1883) (Figure 5).

Hydrotherapy is an example of a non-drug treatment that has

been applied for various afflictions, including headache, since an-

tiquity (Jackson, 1990). It became more popular during the 19th

century, as reflected in various textbooks. Pierre-Adolphe Piorry

(1794–1879), successor to Trousseau at the Hotel Dieu in Paris,

wrote a treatise on hemicrania (1831) in which he advised stimu-

lation of the feet by warm water: ‘A quick stimulation of the feet

by warm water or the firelight has sometimes suddenly stopped

the migraine’ (Piorry, 1831). The Berlin physician Moritz Romberg

(1795–1873), in his well-known Manual (Romberg, 1853), wrote

that ‘the natural and artificial waters of Marienbad, Kissingen, or

even Karlsbad. . . are indicated’ if the secretions of the liver and

intestinal glands are depraved. These were well-known spa cities

that were visited by famous composers (Beethoven, Chopin) and

authors (Gogol) in the 19th century. Gowers mentioned ‘water to

the feet’ and ‘a hot bath of mustard’ in his Manual (1888).

Oppenheim advised trying hydrotherapeutic measures and other

physical methods, ‘that should be used in every case, though the

results are not brilliant’ (Oppenheim, 1900). Moses Allen Starr

(1854–1932) emphasized exercise and (Turkish) baths, but also

mentioned ‘a course of treatment in Carlsbad’ and did not write

on more invasive procedures (Starr, 1907). Flatau mentioned cold

water therapy in his review (1914).

Psychological interventionsNeither Liveing (1873) nor Thomas (1887) listed psychological

interventions in their reviews. At the end of the 19th century,

several authors, including Mobius (1894, p. 92), noticed that sev-

eral treatments were based merely on suggestion. Hypnosis was

mentioned by various authors, including Oppenheim (1911,

p. 1189), who advised it for ‘infrequent attacks of true migraine

associated with attacks of psychogenic headache of a similar char-

acter’, and Flatau (1914), who wrote that it worked in only hys-

terical forms of migraine. Jelliffe and White (1917) mentioned

psychoanalysis if recurrent migraines occurred in ‘neurotic individ-

uals’, a treatment that was applied to various diseases in the early

20th century (Jelliffe and White, 1917). Although she was not

found in the textbooks we consulted, it is important to mention

Frieda Fromm-Reichmann (1889–1957), who applied psychoanaly-

sis to migraine patients, explaining migraine as a result of re-

pressed anger (Fromm-Reichmann, 1937). Freud wrote about

the psychodynamic aspects of pain, headache and migraine be-

tween 1895 and 1926 (Karwautz et al., 1996); prior textbooks did

not mention this treatment (Dana, 1892; Dercum, 1895; Church

and Peterson, 1899). In later reviews psychotherapy is hardly

mentioned for migraine, except where it occurred in combination

with psychiatric diseases (Richter, 1935; Boag, 1968).

Surgical procedures

Ear, nose and throat procedures

In the early 20th century, the nose and throat area was

often considered to cause migraine, leading to surgery of the ad-

enoids and tonsils. The German neurologist Hermann Oppenheim

Figure 5 From Mortimer Granville’s (1883) book Nerve-Vibration and Excitation as Agents in the Treatment of Functional Disorder and

Organic Disease.


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(1858–1919) wrote about ‘the treatment of chronic nasal diseases’

that ‘partly relieved and even cured the attacks in some of his

cases’ (Oppenheim, 1900). However, Dana warned that ‘the re-

ported cure of numerous cases of migraine by treatment of nasal

hypertrophies and catarrh should not excite too much confidence

in such measures. In fact, since migraine is a constitutional neur-

osis, one cannot expect permanent results from removing reflex

irritants alone’ (Dana, 1892). Although Samuel A. Kinnier Wilson

(1878–1937) in his Neurology paid attention to mainly drug treat-

ment, he stated that ‘any source of possible infection in teeth,

sinuses, tonsils, etc., must be eradicated. . .’. (Wilson, 1940; 1955).

Treatment based on intracranial pressure:lumbar puncture

Among the central theories mentioned by Flatau was Quincke’s

idea of angioneurotic hydrocephalus (Flatau, 1912, p. 173–82).

One of the invasive procedures applied in the early 20th century

and based on discoveries including lumbar puncture (1891)

(Frederiks and Koehler, 1997), X- or rontgenrays (1895) and

increased knowledge of intracranial pressure (Koehler and

Wijdicks, 2008) was lumbar puncture for migraine, in which

increased intracranial pressure was assumed. Schuller (1909)

believed that increased intracranial pressure could be recognized

on skull radiographs; he even proposed trepanation, craniotomy

and palliative trepanation of sella with third ventricle puncture.

Heinrich Irenaeus Quincke (1842–1922), the first person to per-

form a lumbar puncture, found relief in two of three patients

whom he punctured during a migraine or periodic headache at-

tacks. Flatau, who referred to these cases, was able to confirm this

in a young boy, but he warned of the headache-inducing effect of

lumbar puncture in weak and pale persons (Flatau, 1912, p. 227).

Various

In the fourth edition of his text, Osler added the following treat-

ment in ‘obstinate cases’: ‘An ordinary tape seton may be inserted

through the skin at the back of the neck, to be worn for three

months, a plan of treatment which has the strongest possible rec-

ommendation from Mr. Whitehead, of Manchester (Osler, 1901).

Osler probably referred to a paper in the British Medical Journal

published by the English surgeon Walter Whitehead (1840–1913;

Whitehead, 1901). In fact this method reverted to humoral

medicine.

Operations on the sympathetic nervous system

In the 17-volume (18 books) Handbuch der Neurologie edited by

Bumke and Foerster, Hugo Richter (1935) reviewed several surgi-

cal treatments. At the time, migraine was considered a vasospastic

disorder, not a disorder of abnormal vasodilatation, and therefore

a vasodilatory treatment was thought to be necessary (Tfelt-

Hansen and Koehler, 2008). This resulted in procedures of the

cervical sympathetic, including upper ganglion and periarterial

sympathectomy, with the purpose to dilate the pertinent arteries.

Several authors had applied and described these procedures. The

French physicians Lermoyez and Jean Athanase Sicard (1872–

1929) carried out periarterial sympathectomy of the temporal

artery. The American neurosurgeon Walter Dandy (1886–1946)

operated on the cervical and first thoracic ganglion (reporting

two cases that were pain free for 7 and 4 months, respectively)

(Richter, 1935). Surgery on the sympathetic nervous system was

not unique for migraine, as it was applied, for instance, for the

treatment of causalgia by Leriche and Tinel during World War I

(Koehler and Lanska, 2004).

The English neurosurgeon Geoffrey Knight reviewed surgical

treatments in Vinken’s and Bruyn’s Handbook of Clinical

Neurology in the late 1960s (Knight, 1968). Even in this period,

the vasospastic theory of migraine was still used as a basis to carry

out surgical procedures that included cervical sympathectomy bi-

laterally, inferior cervical and first thoracic ganglion, stellate gan-

glion excision, cervicothoracic ganglionectomy and periarterial

sympathectomy of carotid bifurcation. Cases of what today we

would call migraine with aura and hemiplegic migraine were

included (Knight, 1968).

Following the vasospastic theories of the early 1900s, John

Graham (1879–1950) and Harold Wolff (1898–1962) showed

that migraine should be considered a problem of abnormal vaso-

dilatation (Graham and Wolff, 1938; Wolff, 1948; Koehler and

Isler, 2002; Tfelt-Hansen and Koehler, 2008). Therefore ligation

of vessels rather than sympathicolytic procedures came into

vogue. Middle meningeal vessel procedures were carried out by

the Swedish neurosurgeon Herbert Olivecrona (1891–1980; re-

ported in 1947) and common carotid artery procedures by

Geoffrey Knight (1968). He warned that it should only be done

in carefully selected cases and that the only indication was ‘relief

of localized retro-orbital pain which can be consistently relieved by

carotid compression’ (Knight, 1968). Surgical treatment of the

sympathetic was also advised by Wilson if all ordinary measures

were ineffective (Wilson, 1940; 1955).

Operations on the afferentsensory pathwaysIn his review on surgical procedures in migraine, Knight (1968)

also reviewed procedures carried out on the afferent nerve path-

ways since the early 20th century. Neurosurgical procedures were

mentioned, including those by the American neurosurgeon Harvey

Cushing (1869–1939), who warned not to spare the ophthalmic

division of the trigeminal nerve (1904); the Canadian neurosur-

geon Wilder Penfield (1891–1976), who treated the ophthalmic

fibres (1932); Wilfred Harris (1869–1960), who injected around

the gasserian ganglion (1936); George Frederick Rowbotham,

treating the supraorbital and supratrochlear nerves (1942);

Olivecrona, who performed intramedullary tractotomy (1947);

and Knight himself, who stated that ‘sensory root section is justi-

fied when the pain is repeated and severe and. . . . [E]rgot leads to

toxic features’. Other nerves have also been used as a target for

neurosurgical procedures, including the occipital, post-auricular

and auriculotemporal (Knight, 1968).

ConclusionWe found that non-drug treatment is a phenomenon of all ages

and was reserved for headache and migraine that did not react to

the usual treatments of the period. A large variety of treatments


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(Table 2) have been tried, and these were based mainly on con-

temporaneous pathophysiological models that were applied not

only for headache but for various other afflictions, some of

which we have mentioned. Although success rates are not avail-

able, these treatments do not seem to have been very successful.

After its introduction in the 18th century, electricity became more

popular following the vasomotor theories of the mid-19th century,

but toward the end of the 19th century, disappointing results

were reported, e.g. from Gowers and Osler. Mobius believed sug-

gestion played an important role, but his opinion should also be

considered against the background of his fight against the neuro-

logical establishment of Erb, Edinger and others. Wilhelm Heinrich

Erb (1840–1921) complained that Mobius endangered materialist

medicine, but Mobius said that suggestion could and should be

used by physicians. Freud, who had used Erb‘s ‘bible’ of electro-

therapy (Erb, 1882) in his practice, came to the same conclusions,

naming Mobius as a founder of psychotherapy. There was not just

a ‘problem of suggestion’ that Mobius recognized, but also a

chance for medical thinking to overcome its fixation on mechan-

ism (Schiller, 1982, p. 24–5; Steinberg, 2005, p. 109).

Mobius’ idea may be applicable to many of the methods dis-

cussed above. It is well known that ‘placebo-associated improve-

ment’, as discussed in a recent review by Diederich and Goetz

(2008), occurs frequently when treating pain syndromes.

Knowledge of the effect has advanced over past years. It depends

on the invasiveness of the procedure and is influenced by the

patient’s awareness of the procedure, suggesting an expectation

or reward component. In pain syndromes, endogenous opioid

release triggered by cortical activation, in particular the rostral

anterior cingulate cortex, is associated with placebo-related

analgesia. It can be reversed by opioid antagonists (Diederich

and Goetz, 2008). Similar effects may have played a role in psy-

chological interventions (psychoanalysis) that were applied

in particular for neurotic migraine sufferers, again a treatment

that was applied for other diseases that were considered psycho-

genic by some physicians at the time, e.g. dystonia (Munts et al.,

2010). Best medical practice has always included an implicit role

for ‘tender loving care’ as an important factor of all interactions

between patients and caregivers (Diederich and Goetz, 2008).

After a period of relative silence in the 20th century, electricity

has recently gained interest again, with new insights into patho-

physiology and targets as well as the availability of refined pro-

cedures (Goadsby et al., 2010). It is called neuromodulation and

includes deep brain stimulation, occipital nerve stimulation and

transcranial magnetic stimulation. However, the problem of sug-

gestion, recognized by Mobius at the end of the 19th century, still

plays a role and, although better understood today (Diederich and

Goetz, 2008), is still not easy to deal with, e.g. with respect to

occipital nerve stimulation, where placebo effects are still a matter

of concern (Burns et al., 2007) and need to be overcome by

sophisticated methodology.

Present-day invasive treatments for headache should be con-

sidered against the background of the long list of procedures men-

tioned in this article, especially given that older theories such as

the importance of sympathetic dysfunction in migraine (Peroutka,

2004) and electricity (Goadsby et al., 2010) with their inherent

methodological problems are revived from time to time.

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Table 2 History of non-drug treatments in relation to pathophysiological theories of the period, completed with moderninvasive procedures for various headache syndromes

Pre-1800 period

Based on humoral theories (balance of the four humours)

Often referred to Galen and Aretaeus

Electricity added in 18th century

Modern period

Based on new solid (organ-based) theories

Scientific method introduced into medicine

Electricity becoming an important tool

Vasogenic theories led to vascular procedures (carotid, sympathetic)

Awareness that effect of several non-drug treatments was due to suggestion

20th century

Psychological interventions

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Old procedures still used (at least in alternative medicine)

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Cortical hypersensitivity theories (transcranial magnetic stimulation for migraine)

Peripheral triggers (patent foramen ovale procedures for migraine)


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