Headache: A History

In 1964, author and critic Susan Sontag published a little-known short story entitled ‘Man with a Pain’. It is an eloquent reflection not only on the difficulties patients face when attempting to communicate ‘invisible’ forms of pain to others, but also to the struggle that witnesses to their suffering experience in expressing sympathy.

The problem for Sontag’s ‘man with a pain’ is that no-one can ‘see’ the intense pain he is feeling. He has ‘turned stiff and awkward by misery’ but when he telephones a friend and ‘tells her of his misfortune’, she looks distracted and dashes away. He ‘wants to scream, but he’s afraid of being dragged off to Bellevue’. When he visits another friend, he first gets permission to speak and then

he hauls the sorrow up out of his throat. It comes out in bits and pieces. Poor shriveled thing. It doesn’t come out whole, because it doesn’t come out as a scream.

The overwhelming experience of chronic pain, the authentic expression of which is a scream that drowns out worlds of sociability, is therefore denied, swallowed. As the ‘man with a pain’ discovers, pain creates rifts between people. The ‘man with a pain’ confesses to being ‘tightly wrapped, swathed, and buttoned into his pain. He is embalmed in it, like a mummy’. The feeling of hurting is all-encompassing. It is an ‘embrace’ that engulfs his world.

Throughout Sontag’s ‘Man with a Pain’ there is a throbbing headache or trigeminal neuralgia – the clinical diagnosis doesn’t matter to Sontag or the ‘man with a pain’. What matters is that ‘he is in pain’, although no-one around him can see anything wrong. It is a complaint that appears time and again for headache sufferers in the real, as opposed to fictional, world. As the distinguished physician Peter Latham wrote to novelist Harriet Martineau on 16 April 1855, ‘I presume that the pain which you describe is neuralgic’, but ‘This is as much as to say “the pain is the pain” – and does not sound very wise’. What matters is pain: pain that transforms everyday objects and surroundings into adversaries; pain that spawns a disconnect between ‘me’ and ‘my body-in-pain’. The sufferer’s body becomes the weapon itself, destroying the very language that could be used to objectify it. Agency is jettisoned. The body is crushingly present.

Looked at historically, however, patients with neuralgic headaches have not been totally silenced. In the archives and medical libraries, we find eloquent descriptions of their suffering, either directly provided by patients or reported by their caregivers. In 1809, for example, neuralgia was described by one unnamed sufferer as turning every nerve into a ‘red-hot, wriggling, reel-dancing viper’. For another patient, writing in 1816, it felt ‘as if a heated knife… was piercing or screwing into the flesh’ or was like ‘hot pincers… tearing or twisting it from the bone’. In a letter dated 29 February 1823, novelist Fanny Burney complained that her head felt ‘as if a hundred windmills were turning round’. In 1890, a patient with a frontal headache described it as possessing ‘a bursting character, as of the eyes were being thrust out’ while a sailor complained that his headache threatened to ‘unship the top of his head’. Later that decade, a patient at the London Hospital simply described her ‘dreadful effervescing headache’ as ‘something awful’. Time and again, sufferers in letters, diaries, and medical texts evoked images of facial neuralgia as an ‘arch-fiend’ that ‘comes to visit us’ or a ‘powerful electric shock…. as if somebody was jabbing me with a red-hot knife’. The range of suffering was aptly captured in an advertisement for a cure for trigeminal neuralgia: it described the ‘character’ of the pain as including a feeling of ‘stabbing, tearing, grinding, gnawing, cutting, tingling’ – then added that the pain might also include ‘all combined’. Was it any wonder that George P. Hachenberg’s Medical Consultation Book (published in 1893) listed 96 prescriptions for headache alone and an additional 119 medicines that were also potentially beneficial for such sufferers?

Historically, patients and physicians routinely claimed that headaches served a positive function. For many, religion conferred cosmic value on suffering. As the Rev. Thomas Brock in the mid-nineteenth century explained, his ‘exceedingly violent’ paroxysms of facial pain were sent as a ‘test’ of his ‘spiritual state’. It was better to suffer in this life, not the next, he believed. Writing in his diary at around the same time, the Presbyterian Thomas Smyth admitted that his spasmodic attacks of head pain made him ‘very faint’ and he had ‘even screamed’, but ‘I told all to Jesus. I cast all upon him’. Smyth pleaded with God to ‘cleanse me from secret faults…. I told him I was a poor, perishing, helpless sufferer – perhaps through my own imprudence and fault, though I could not account for my present severe attack’. In other words, on the one hand, Smyth needed to show submission to his preordained destiny: after all, the wages of sin were pain and eventually death. On the other hand, he desired Christ to know that whatever ‘faults’ he had committed, they were ‘secret’ (meaning: unknown to himself) and, he believed, were incommensurate with the severity of his current attack.

The religious meanings given to the suffering caused by pain such as headache cannot be over-estimated, but it was not necessary to appeal to a Higher Being. Secular commentators, whether physicians or patients, might also conceive of the protective function of pain in metaphorically theological terms. Headache pain was the ‘prayer of a nerve for healthy blood’; it was the ‘protector of the voiceless tissues’, as popular physician John Milner Fothergill put it in a textbook for ‘young practitioners’ in 1884. Time and again, physicians and other commentators reminded sufferers that pain ‘stands sentinel to our vices’.

But what if headache pain was not a sign; what if there was no behaviour to be improved and no obvious lesion to be repaired? In his book From Lesion to Metaphor. Chronic Pain in British, French, and German Medical Writings, 1800-1914 (2000), Andrew Hodgkiss explains that, throughout the nineteenth-century, physicians generally assumed that there was no pain without lesion. As physician T. Lauder Brunton put it in an article entitled ‘On the Pathology and Treatment of Some Forms of Headache’ (1883), pain was a ‘useful monitor, warning the individual to stop the mischief which is occurring before it is too late’.  In those cases where the physician was unable to identify what was causing the pain, Brunton insisted that it was ‘possible, and indeed probable, that some morbid condition may be present which has escaped our notice’. The trick was to keep looking: pathology was there, somewhere. It was not possible to countenance the idea that pain signified nothing.

A lively debate developed about what might be causing the increasing frequency of headache from the late nineteenth-century. ‘Modernity’ itself was thought to be the culprit of this affliction as well as many others. Numerous medical commentators insisted that the headache was the result of modern societies rendering brains ‘overfull of blood’. Headache was a disease of civilization. In 1895, Arthur Symons Eccles (Fellow of the Royal Medical and Chirurgical Society and prominent member of the Medical Society of London) claimed that the ‘conditions of everyday life’ were ‘conducive to the development of headache’. He believed that one of the chief culprits was ‘rapid means of communication’.

Such beliefs influenced treatment regimes in the UK as well as the US. If the cause of headache was brains being ‘over full with blood’, then simple solutions included ‘reducing the quantity of blood circulating through the brain’. Eccles explained that this could be done by ‘drawing the blood from the head’, through using a ‘hot footbath’ or ‘by general depletion’ such as sweating or purging the body of ‘waste matters’.

However, if the cause was actually ‘poverty of the blood’, then nourishment was essential. This was the emphasis of most over-the-counter pharmaceuticals. For example, a 1906 advertisement for ‘Bile Beans’, noted that the nerves of people suffering from neuralgia ‘need nourishing’. ‘Bile Beans’ worked by ‘feeding and strengthening the blood, and keeping the nerves healthy and active’. Time and again, health commentators insisted that diet was crucial in alleviating the pain of headache. In the words of one medical journalist, writing in 1881, sufferers of headaches needed ‘plenty of good soups, oysters, rump steaks, &c. washed down with good stout or port wine, not spirits’. It was a cure designed for and marketed to the wealthy.

Blaming ‘modernity’ for human headaches started to take second place to personality from the 1930s onwards.  In ‘Preliminary Report on Personality Studies in Thirty Migraine Patients’ (1935), for instance, Dr. Olga Knopf of Bellevue Hospital (where Sontag’s fictional ‘Man with a Pain’ feared being sent) concluded that migraine sufferers possessed distinctive personality traits: they were hostile, resentful, and guilty personalities.

The psychological makeup of headache sufferers was pathologised even further from the 1960s. Headaches became signs of ‘psychological disturbance’. As Harold Merskey (the physician in psychological medicine at the National Hospital for Nervous Diseases in Queens Square, London) informed fellow-physicians in 1968, the typical sufferer of neuralgia was ‘a married woman of the working or lower-middle class, possibly once pretty and appealing, but never keen on sexual intercourse, now faded and complaining’. This insistence on the gender of chronic pain is characteristic in discussions of facial pain.

Even today, there is a tendency amongst physicians to pathologise people suffering chronic pain conditions involving headache. It is not that they lack sympathy: ‘invisible’ pains that resist attempts of alleviation are frustrating for caregivers.  As Sontag’s ‘Man With a Pain’ recognized, pain creates rifts between the sufferer and his or her friends, physicians, and even strangers. But the ‘man with a pain’ also reminds us that witnessing pain makes political claims about the distribution of sympathy. The way we respond to people-in-pain strikes at the heart of what it means to be human.

If you are interested in this topic, take a look at my book, The Story of Pain: From Prayer to Painkillers.