Saturday, September 28, 2002
Hell in the Head – On the torture that makes people wish for death: migraines. And on the hope for an end to the torment. A pain researcher from Kiel shows new ways in the treatment of the widespread ailment of headaches.
by Klaus Podak
An explosion in the head that refuses to end. Being alive is hell, wildly pounding, pulsating, hammering furiously. Existence: nothing but torment, utter pain. Perhaps nausea, perhaps vomiting. Add to that extreme sensitivity to light and noise. Darkness and absolute silence become means of survival. This lasts for three hours—if the victim is lucky. Seventy-two hours—if the victim is unlucky. After that, the torture subsides. What remains is fear. Because the victim knows: Hell will return. Sometime. Soon.
She will send messengers. The victim knows them. He often misunderstands them, believing them to be the cause of what is to come. But the hellish process has already begun again with them. The messages form its preface.
These messages are quite varied, often even contradictory. They manifest in countless combinations. They speak through irresistible changes in the victim's behavior. These can include fatigue, depression, lack of energy, irritability, or, conversely, sudden bursts of creativity, elation, and restlessness. Even something as trivial as excessive yawning can be a message. Or intense hunger. Feeling cold or sweating without any external cause. Then the embers of hell are already smoldering.
In some cases—roughly ten percent of victims—phenomena occur that are referred to with the somewhat euphemistic term "aura." Originally, aura meant "breath of air," later the special aura that can emanate from a person. None of these somewhat solemn connotations apply here. Aura now means: zigzag lines in the field of vision, flickering vision, dizziness, tingling sensations, speech difficulties, paralysis, concentration problems, fatigue, even unconsciousness. These disturbances develop within five to twenty minutes. They can overwhelm their victims for up to an hour. Immediately or after a short break, an attack occurs. If it recurs regularly, it can drive the victim to suicide. This torture, which makes people wish for death, is called migraine.
Tip from the bakery
There was a time—and it's far from over—when invoking this ailment in public was considered a convenient excuse, especially for ladies of the upper classes. "After lunch, Director Pogge got a migraine. Migraines are headaches, even when you don't actually have one." That's how it's described by Erich Kästner in the story "Pünktchen und Anton." It may well be that self-diagnosis often served only to satisfy the need for rest and strict isolation. In any case, it worked, even if it was met with mild derision. This, however, reveals a respect for genuine migraines, against which there was simply no remedy. Nowadays, much can be done to combat the torment of migraines. But they cannot be made to disappear completely.
Migraine is a disease, a disease in its own right, not a symptom of anything else
"That's what Hartmut Göbel, who should know, says," says Göbel. A gentle, calm, and very attentive 44-year-old, he is a certified psychologist and professor of medicine, specializing in neurology. As chief physician, he heads a unique institution in Germany, the Kiel Pain Clinic, a model clinic for—and this combination is crucial—neurological-behavioral pain therapy (in cooperation with the AOK health insurance company). Because it's not just about finding the right medication; the patient's behavior must be changed. The whole person suffering from pain must change, must become active themselves. Simply passively accepting medical treatment isn't enough.
Göbel's specialty, however, is "headaches." Under this title, he has published a 901-page standard work that is constantly cited in specialist literature. He has also written an extremely helpful standard work for those affected, for headache sufferers. This year, the third, completely revised and updated edition was published by Springer. (Hartmut Göbel: "Successfully Combating Headaches and Migraines", 444 pages, €19.95).
Never before has there been so much awareness about this most common type of pain. In Germany, according to a representative survey, 71 percent of the population suffers from headaches at least occasionally during their lifetime. That's around 57 million people. Many of those severely affected have experienced the most absurd histories. They are lucky if they finally find their way to Göbel's pain clinic, often by pure chance.
Take Marlene Völlink, for example. For years, the baker's wife was struck by migraines five to six times a month. Lately, at least, it was down to three. Of course, these attacks were unbearable, too. At six in the morning, she would pop the first pills, the usual headache tablets with caffeine. A second dose at midday, and another in the evening. It didn't help at all. Göbel often talks about headaches that are actually caused by such attempts at self-medication with pills.
In her desperation, Marlene Völlink had tried almost everything. She consulted faith healers. She had acupuncture. She had her neck adjusted. She rearranged the beds in her bedroom because, supposedly, underground water veins were having a sinister influence on her head. Nothing helped. Then, finally, the right tip came from a customer of her bakery. Five months after her application, she was admitted to the Kiel Pain Clinic. After just three days of intensive treatment, she felt relief. She experienced one more attack while still in the hospital. Since then, she has been feeling much, much better. She hopes it stays that way.
Diagnosing the correct type of headache alone is no easy task. Listening to Hartmut Göbel, one truly understands why such a highly specialized clinic, where diagnosis, therapy, and research go hand in hand, is even necessary. According to Göbel, experts today distinguish more than 165 different types of headaches. Eighteen subtypes have been identified for migraines alone. No matter how empathetic, a general practitioner cannot differentiate between all of these in severe cases, diagnose them correctly and reliably, and treat them effectively. They simply don't have the time. And how, then, are they supposed to also practice and monitor the essential behavioral changes with their patients?
Like with sunburn
People who suffer from migraines are often very sensitive, easily offended, irritable in a positive sense, and perfectionistic. They readily take on responsibility and then feel responsible for everything—perhaps too responsible. However, this by no means justifies a purely psychological explanation of the causes. People with these characteristics are subject to a genetically determined predisposition of their nervous system, which makes them susceptible to very specific physical changes that manifest as migraine attacks. To illustrate this, Göbel uses the example of sunburn. No one has to get it. But individuals with a certain skin type are simply more prone to it when exposed to the sun.
Göbel's migraine patient, Andra Sprotte-Putnins, readily admits her perfectionism. She is—or rather, she was—a teacher (German and Protestant religion). At the age of 44, she was forced into early retirement, suffering kidney damage from excessive attempts at treatment with medication. She experienced her first migraine attack when she was 30, two or three times a year. By the 1980s, this had increased to six or seven attacks per year. Since 1995, she has had twelve days of pain per month. She was eventually prescribed triptans, the most modern class of migraine painkillers. Even these no longer helped. The illness, as is the case for many migraine sufferers, led to a reduction in her social contacts, which she experienced as a bitter loss. A dedicated pharmacist recommended the Kiel clinic to her: a three-month waiting list, then admission for the standard three weeks as an inpatient, with a one-week extension. First, she stopped taking painkillers, then she was prescribed antidepressants, which sometimes work well for migraines, even if the patients aren't actually depressed. She's learned that she needs to change her perfectionistic behavior. She wants to continue practicing what she learned in Kiel at home in the long term. Göbel's holistic approach makes perfect sense to her. Perhaps she won't be able to completely overcome migraines. "But," she says, "you learn to deal with them differently."
Migraine is a complex condition. However, Göbel summarized the underlying mechanism common to all its forms in a few sentences: “The basis for the recurring pain attacks is an increased sensitivity of the nervous system to sudden external or internal stimuli. This particular sensitivity is partly due to inherited genetic information. As a result, strong changes in stimuli trigger an excessive release of neurotransmitters in the brain. This leads to painful inflammation of the blood vessels in the brain.”
Everything is interconnected: The brain's extreme irritability is innate. If this irritability is acted upon, it triggers a physical reaction in the brain, an excessive release of neurotransmitters. These attack blood vessels, leading to inflammation. It's important to note that the attack itself is not a disease of the brain. In fact, the brain doesn't even have its own pain receptors. The inflammation affects the blood vessels supplying the brain. This also explains the throbbing, pounding pain that intensifies with the slightest exertion. The faster-pulsating blood flow rhythmically presses against the inflamed areas.
In general: enjoy more
It now becomes clear why behavioral training plays such a crucial role. It's about getting a handle on sensory overload, no longer surrendering to it, whether through excessive attention to even the smallest changes in the surrounding world, or through the perfectionistic attempt to bring the onslaught of impressions completely under control.
A leaflet on pain management, distributed in Kiel, lists ten points on how to deal with oneself. In the margin, they are summarized as follows: “Generally: enjoy life more…”
Before that can happen, the clients of the pain clinic go through a multitude of courses. Progressive muscle relaxation is practiced, of course. Because many of these sick, tense sensory processors have lost the sense of how their body behaves, how it could behave – in a pleasurable way.
Perception is also practiced on the purely mental level of imagination, of fantasy. Freely chosen images of tranquility are to be imagined with closed eyes. One woman sees water before her, another a house. A third tries hard to conjure up a forest with chirping birds. She is trying too hard. "I can't hold it," she says, disappointed. Gently, the therapist encourages her to try again, or perhaps with a different image. Now it becomes a meadow of flowers, with a light breeze and clouds above. These seemingly simple exercises are not at all easy for the patients. They have to conquer new, completely unfamiliar dimensions of experience—and that means self-experience—step by step.
In physiotherapy, headache sufferers, under the guidance of Holger Reinicke, search for movement errors. Pain also alters movement patterns, making them pathological. These patterns need to be corrected. This can only be achieved individually, not according to a one-size-fits-all approach. Reinicke adds an important lesson: "The passive attitude – 'Make me better!' – doesn't work." The goal is to learn that one must actively participate. Even when pain does recur, everyone must consciously and proactively manage it.
Then there's the migraine seminar. A doctor explains the illness, talks about triggers, and strategies for avoiding them. Ultimately, it's about changing your lifestyle. The message constantly repeated everywhere in Kiel is simple. It's just not that easy to put into practice: You have to change your life!
Background: Hartmut Göbel
Hartmut Göbel is the last hope for many suffering from unbearable, neurologically based pain. The medical professor and psychologist heads the pain clinic in Kiel, which has 50 beds for inpatient treatment of chronically ill patients. Göbel's specialty is headaches, especially migraines. A significant part of his work is dedicated to researching them. He considers it important to make the results of his research accessible to a wider audience in the form of self-help guides.