Saturday, September 28, 2002

Hell in the Head - About the torture that makes people wish for death: migraines. And the hope for an end to the torment. A pain researcher from Kiel shows new ways to treat the widespread disease of headaches. Migraine-hell-in-the-head

by Klaus Podak

Explosion in the head that doesn't want to end. Being in the world is hell that throbs wildly, pulsates, hammers wildly. Existence: nothing more than torture, complete pain. Maybe nausea, maybe vomiting. In addition, extreme sensitivity to light and sensitivity to noise. Darkness, absolute silence become means of survival. This lasts for three hours - if the victim is lucky. 72 hours – if the victim is unlucky. Then the torture goes away. What remains is fear. Because the victim knows: Hell is coming back. Sometime. Soon.

She will send messengers. She knows the victim. It often misinterprets them, believing them to be the cause of what is to come. But the hellish process has long since begun again with them. The messages form his foreword.

These messages are very different, often even contradictory. They appear in a variety of combinations. They speak of indomitable changes in the victim's behavior. These can consist of tiredness, depression, lack of energy, irritability or, on the contrary, sudden bursts of creativity, elation and restlessness. Even something as banal as excessive yawning can be a message. Or cravings. Freezing or sweating without causes in the outside world. Then the infernal tinders are already smoldering.

For some - we are talking about ten percent of the victims - phenomena now occur that are called, in a subtle word, “aura”. Aura originally meant “breath of air”, later the special charisma that can emanate from a person. None of that bit of celebratory stuff in this case. Aura, that now means: zigzag lines in the visual field, flickering vision, dizziness, tingling sensations, speech disorders, paralysis, difficulty concentrating, fatigue, even unconsciousness. These disorders develop in five to twenty minutes. They control their victims for up to an hour. An attack occurs immediately or after a short pause. If it returns regularly, it can drive the victim to suicide. This torture that makes people wish for death is called migraine.

Tip in the bakery

There were times - they are far from over - when citing this suffering was considered a convenient excuse in public, especially by women of higher classes. “After lunch, Director Pogge got a migraine. Migraines are headaches even if you don’t have one.” This is what Erich Kästner says in the story of “Pünktchen and Anton”. It may be that the self-diagnosis often only served the need for peace and strict isolation. In any case, she seemed mildly laughed at. However, this shows a respect for real migraines, against which nothing could be done. Nowadays there is a lot that can be done to combat the torture of migraines. You can't make them disappear completely.

Migraine is a disease, a disease in its own right, not a symptom of anything else

says Hartmut Göbel, who needs to know. Göbel, a gentle, calm, very attentive man of 44, is a qualified psychologist and professor of medicine, specializing in neurology. As head physician, he heads a facility that is unique in Germany, the Kiel Pain Clinic, a model clinic for - this combination is crucial - neurological-behavioral medicine pain therapy (in cooperation with the AOK). Because it's not just about finding the right medication, the patient's behavior has to be changed. The whole person suffering from pain must change and become active themselves. It is not enough to passively accept medical blessings.

Göbel’s specialty, however, is “headaches”. Under this title he published a 901-page standard work that is constantly cited in specialist literature. But he also wrote an extremely helpful standard work for those affected, headache sufferers. The third, completely revised and updated edition was published this year by Springer Verlag. (Hartmut Göbel: “Successful against headaches and migraines”, 444 pages, 19.95 euros).

There has never been so much information about this bundle of the most common pains. According to a representative survey, 71 percent of the population in Germany suffer from headaches at least some of the time during their lives. That's around 57 million people. Many of those severely affected have had the most absurd careers. It's their luck when they finally find their way to Göbel's pain clinic, often only by chance.

Marlene Völlink, for example. For years, the baker's wife was attacked by migraines five or six times a month. Finally, at least three more times. Of course these attacks were also unbearable. At six in the morning she took the first tablets, usual headache tablets with caffeine. The second load at lunchtime, another one in the evening. That didn't help. Göbel often talks about a headache that is caused by such attempts at self-medication with tablets.

In her desperation, Marlene Völlink had tried almost everything. She went to faith healers. She went for acupuncture. She strained her neck. She moved the beds in the bedroom because water veins under the house were said to have a devilish influence on her head. Nothing helped. Then finally the right tip from a customer of her bakery. Five months after her application, she was admitted to the Kiel Pain Clinic as an inpatient. After just three days of intensive treatment, she felt relief. She experienced another seizure here in the hospital. Since then she has been doing much, much better. She hopes it stays that way.

Correctly diagnosing the type of headache alone is not child's play. When you listen to Hartmut Göbel, you understand why such a highly specialized clinic, where diagnosis, therapy and research go hand in hand, is necessary. Today, experts use Göbel to differentiate between more than 165 different types of headaches. Eighteen subtypes of migraine alone have been identified. In severe cases, no family doctor, no matter how sensitive, can sort it all out, diagnose it correctly and reliably, and treat it effectively. He doesn't even have the time to do it. How should he then practice and control the essential behavioral change with the patients?

Like sunburn

People who suffer from migraines are often very sensitive, sensitive, irritable in a positive sense and perfectionistic. You like to take responsibility and then feel responsible for everything, too much responsible. However, this is by no means an endorsement of purely psychological causal research. People with these characteristics are subject to a genetically determined disposition of their nervous system, which makes them susceptible to very specific physical changes that manifest themselves in migraine attacks. Göbel uses the example of sunburn to illustrate the situation. Nobody has to get it. But individuals who have a certain skin type simply get it more easily when exposed to the sun.

Göbel's migraine patient Andra Sprotte-Putnins, for example, freely admits her perfectionism. She is, no, she was a teacher (German and Protestant religion). Because at the age of 44 she had to take early retirement, including kidney damage due to excessive treatment attempts with tablets. She experienced the first bout of the disease when she was 30, two or three times a year. In the 1980s there were already six to seven attacks. Since 1995 she has had twelve days of pain per month. She ended up on triptans, the most advanced class of painkillers for migraines. They didn't help anymore either. The illness led, as is the case for many migraine sufferers, to a bitter reduction in their social contacts. A dedicated pharmacist advised her to go to the Kiel clinic: wait three months, then be admitted for the usual three weeks as an inpatient, with a one-week extension. First she took a break from painkillers, then she was given antidepressants, which sometimes work well for migraines without the patient actually being depressed. She has learned that she needs to change her perfectionist behavior. She wants to continue training what she learned in Kiel at home in the long term. You completely understand Göbel's holistic approach. She may not be able to fully overcome the migraines. “But,” she says, “you learn to deal with it differently.”

Migraine is a complex disease. However, Göbel summarized what is 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 suddenly occurring external or internal stimuli. This special sensitivity is partly due to the innate genetic information. As a result, strong changes in stimuli trigger an excessive release of nerve transmission substances in the brain. The result is painful inflammation of the blood vessels in the brain.”

Everything is interconnected: the extreme irritability of the brain is innate. If it is given in and followed through behavior, the brain will have a physical reaction, the excessive release of messenger substances. They attack blood vessels. Inflammation occurs. Mind you: The attack is not a disease of the brain itself. The brain also has no sense of pain. The inflammation affects the blood vessels that supply the brain. This also explains the throbbing, throbbing pain that gets worse with the slightest exertion. The faster pulsating blood flow rhythmically presses the inflamed areas.

In general: enjoy more

It is now clear why behavioral training plays such a crucial role. It's about getting the overstimulation under control and no longer subjecting yourself to it, whether through excessive attention to even the smallest changes in the surrounding world, or through a perfectionistic attempt to completely control the onrushing impressions receive.

A leaflet on pain management that is issued in Kiel lists ten points on how you should deal with yourself. At the edge of the list they are summarized as follows: “Generally: enjoy more. . .”

Until this can happen, the clients of the pain clinic go through a variety of courses. Progressive muscle relaxation is practiced, of course. Because many of the sick, tense stimulus processors have lost the feeling for how their body behaves, how it could behave - in a pleasurable way.

Perception is also practiced on the purely mental level of imagination, fantasy. Freely chosen still images should be imagined with your eyes closed. One woman sees water in front of her, another a house. A third tries hard to evoke a forest of chirping birds. She's trying too hard. “I can’t hold on to that,” she says disappointedly. The therapist gently encourages her to try it again or with a different image. Now it will be a flower meadow, with a light wind, clouds above. These seemingly simple exercises are not easy for patients. Step by step you have to conquer new, completely unfamiliar dimensions of experience and that means self-awareness.

In physiotherapy, headache sufferers look for movement errors under the guidance of Holger Reinicke. Pain also changes movement patterns. They become pathological. They should be put back in order. This can only be done individually, not according to the same rules for everyone. An additional important experience, says Reinicke: “The passive attitude – make me healthy! - doesn't work." What should be learned is that you have to do something yourself. Even with the pain, if it does come back sometimes, everyone has to consciously deal with it on their own.

Then there is the migraine seminar. A doctor explains the illness, talks about trigger factors and strategies to escape them. Ultimately it's about changing the rhythm of life. The message that is constantly circulating everywhere in Kiel is simple. But it's not that easy to implement: you have to change your life!

Background: Hartmut Göbel

Hartmut Göbel is the last hope for many who suffer from unbearable, neurologically caused pain. The medical professor and psychologist is head of the pain clinic in Kiel, where chronically ill patients are treated in 50 beds. Göbel's specialty is headaches, especially migraines. A significant part of his work is devoted to researching them. It is important to him to make the results of his research available to a large audience in guide form.