Have you ever heard of drilling a hole into the skull to relieve migraine pain? If there is one stock stereotype in the history of migraine, it is that drilling a hole in the skull was once used as an early treatment for migraine.
Where does this idea come from? Is it actually true?
The following is an excerpt from Katherine Foxhall's book Migraine: A History, published by John Hopkins Univesity Press. The images and titles have been added here to better fit an online format.
The word "trepanation" comes from the Greek trypanon, meaning "a borer." The word "trephine" dates from the seventeenth century and comes from the Latin tres (three) and finis (ends). Both denote the technique of removing bone by scraping, sawing, drilling, or chiseling.
The earliest known trepanned skulls date from around 10,000 BCE, in North Africa. There are accounts of the technique of drilling holes into skulls as a therapeutic measure in the Hippocratic corpus, when it was used mostly in cases of fracture, as well as for epilepsy or paralysis. In the second century, Galen also wrote of his experiments with trepanation on animals in his clinical studies.
Migraine Surgery?
But in general, the reasons for trepanning remain unknown, and there is a distinct lack of definite examples, particularly in relation to migraine. A fifteenth-century Ottoman source suggests that physicians may have treated chronic migraine surgically, by sectioning the superficial temporal artery, but this certainly does not imply trepanation.
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While some neurologists have suggested that there is evidence "trephination was performed . . . as late as the seventeenth century," in his London Practice of Physick, published in 1685, Thomas Willis stated quite clearly that although William Harvey had suggested it, actually opening the skull with a "trepand iron" had been "tried as yet by none." There is, however, one known example from the seventeenth century. A barber surgeon, Wilhelm Fabry von Hilden, used trepanation for chronic headache and as a treatment for depressed fractures, but recent authors have acknowledged that there is little evidence to suggest that trepanning has been carried out for migraine.
So where did this persistent idea come from?
In 1902, the Journal of Mental Science published a lecture by Sir Thomas Lauder Brunton, physician to St. Bartholomew's Hospital in London. He was well known for his work on pharmacology. Brunton's lecture on visual and sensory perception was an eclectic mix of ocular and neurological theory, armchair anthropology, excitement about the potential of wireless telegraphy, and interest in the organic and pharmacological causes of defective vision. In it, he discussed premonitions, telepathy, hypnotism, and hallucinations before moving on to epileptic and migrainous aura.
Mystical Fairies or Migraine Aura?
Brunton believed migraine was the result of both arterial contraction and dilatation, a theory that could account for the varied phenomena of migraine if the arterial spasms extended far enough down the artery to affect the centers for hearing, taste, smell, and vision. One of Brunton's proposals was that superstitious visions of fairies "were nothing more than the coloured zigzags of migraine modified by imagination," and, in some cases, by an abnormal condition of the eye. That these fairy sightings were so often accompanied by the jingling of bells, he elaborated, was further evidence of nerve center stimulation causing auditory hallucinations.
Adding some amateur ethnography into the discussion, Brunton went on to suggest that sick headaches were perhaps more frequent "amongst highly sensitive members of civilised communities, but it is probable that they have existed at all times and amongst all peoples, and wherever they have been present they may have led to visions."
This observation led Brunton to his next suggestion: the openings bored into Stone Age skulls when the person was alive had been made during episodes of migraine. Paul Broca, a French physician, surgeon, and anthropologist, caused considerable excitement during the 1870s when he confirmed that ancient skulls recently discovered in Peru and France had been opened surgically during life, and that those individuals had survived long enough for the bone to begin to heal.
According to Broca, the procedure might have been performed during childhood for some religious or social reason. He theorized, on the basis that Neolithic peoples could not have had any real understanding of the brain, that these skulls had been opened in order to release evil spirits. Thus it was only a small leap of imagination for Brunton to suggest that these surgeries had been undertaken to cure migraine.
"To any sufferer from sick headache the first idea that suggests itself is that the holes were made at the request of the sufferers in order to 'let the headache out’," Brunton observed, "for when the pain of headache becomes almost unbearably severe, an instinctive desire sometimes arises either to strike the place violently in the hope of relieving the pain, or to wish that some operation could be done to remove the pain."
In some ways, trepanning does seem an entirely logical response to the intense pain of migraine headache. As Andrew Levy notes: "It is the right external drama, proportionate to the drama inside. . . . The migraining head wants to be cut open; it longs to be cut open." Apart from a reference to French surgeon Just Lucas-Champonnière's 1878 study of trepanation, which claimed that some South Sea islanders still performed this a procedure, Brunton's conjecture about trepanning for migraine was as entirely speculative as his thoughts on fairies: the product of a heady mix of amateur anthropology, medical antiquarianism, post-Darwinian racial theorizing, emergent knowledge about the brain, and fascination with the prospect of modern cranial surgery.'
Nevertheless, his theory soon gained a life of its own.
The Myth of Trepanation Persists
By 1913, William Osler was stating as fact that trepanation operations had been used "for epilepsy, infantile convulsions, headache, and various cerebral diseases believed to be caused by confined demons." By the 1930s, the specific association of trepanning with migraine had become well established. In an article in the Lancet, T. Wilson Parry reasoned that the large numbers of trephined skulls found throughout France could not all be accounted for by epilepsy.
He, therefore, proposed that the procedure had become "instituted as a rite for the casting out of other devils." According to Parry, the next class of demons to be tackled would be disorders with "head-symptoms," including "persistent chronic headache, migraine, chronic neuralgia with acute exacerbations, alarming attacks of giddiness, with or without singing in the ears, and distracting noises of the head."
From these almost entirely unsubstantiated hypotheses, the notion of trepanning for migraine has become so commonly accepted that it now is one of the few things many people think they know about migraine's history. It is somewhat ironic, that the only substantial evidence we do actually have of surgeons cutting holes in skulls for migraine comes from the twentieth century.
Reproduced from Migraine: A History by Katherine Foxhall, Copyright 2019 by Johns Hopkins University Press. Reprinted with permission.
Notes
- Arnott, Robert, Stanley Finger, and Christopher Upham Murray Smith, Trepanation: History, Discovery, Theory. Amsterdam: Swets & Zeitlinger, 2003.
- Brunton, Thomas Lauder. Hallucinations and Allied Mental Phenomena, reprinted from Journalof Mental Science (April 1902). London: Adlard & Son, 1910.
- Ganidagli, Suleyman, Mustafa Cengiz, Sahin Aksoy, and Ayhan Verit. “Approach to Painful Disorders by Şerefeddin Sabuncuoğlu in the Fiftenth Century Ottoman Period.” Anesthesiology 100, no. 1 (2004): 165–169.
- Levy, Andrew. A Brain Wider than the Sky. New York: Simon & Schuster, 2009.
- Rapoport, Allan, and John Edmeads. “Migraine: The Evolution of Our Knowledge.” Archives of Neurology 57, no. 8 (2000): 1221–1223
- Willis, Thomas. The London Practice of Physick. London: Thomas Basset & William Crooke, 1685.
- Osler, William. The Evolution of Modern Medicine: A Series of Lectures Delivered at Yale University on the Silliman Foundation in April, 1913. New Haven, CT: Yale University Press, 1922.
- Parry, T. Wilson. “Neolithic Man and the Penetration of the Living Human Skull.” The Lancet218, no. 5651 (19 December 1931): 1388–1390
