Neurosurg Focus 36 (4):E9, 2014 ©AANS, 2014 The history of craniotomy for headache treatment RACHID ASSINA, M.D., CHRISTINA E. SArrIS, B.S., AND ANTONIOS MAmmIS, M.D. Department of Neurological Surgery, New Jersey Medical School, Rutgers University, Newark, New Jersey Both the history of headache and the practice of craniotomy can be traced to antiquity. From ancient times through the present day, numerous civilizations and scholars have performed craniotomy in attempts to treat head- ache. Today, surgical intervention for headache management is becoming increasingly more common due to im- proved technology and greater understanding of headache. By tracing the evolution of the understanding of headache alongside the practice of craniotomy, investigators can better evaluate the mechanisms of headache and the therapeu- tic treatments used today. (http://thejns.org/doi/abs/10.3171/2014.1.FOCUS13549) KEY WORDS • headache • migraine • craniotomy • trepanation EADACHE has been described as long as human From Prehistory Through the Babylonian Period history has been recorded, having made its way into myth, magic, theology, and medicine. It has The prehistoric era was marked by the lack of un- Htouched ordinary, privileged, and famous people, baf- derstanding of the human body and of the concept of fling the minds of the earliest physicians, who eagerly disease and its origin. This period is also known in the sought for means to explain its occurrence and methods neurosurgical field as the age of trepanation; that is, the for its treatment. Its history can be traced back at least removal of a piece of bone from the skull. Whereas the 4000 years to Mesopotamian ritual texts.14 Headache was earliest documented descriptions of headache only date initially viewed as a spiritual entity rather than a symp- back 4000 years, its treatment may be traced back to the tom of various physical diseases. Scholars from numer- trepanation of Neolithic skulls 9000 years ago (Fig. 1). It ous cultures and historical eras have contributed greatly is believed that trepanation was used to treat headaches by giving evil spirits a physical route to leave the ailing to our modern-day understanding of the classification, 3 pathophysiology, and treatment of headaches. Although head. In the Mesopotamian period, headache was attrib- the first descriptions of headaches, migraines, and neural- uted to gods and evil spirits, in particular to Tiu, the evil gias were recorded by the ancient Egyptians in the Ebers spirit of headache. Treatment was based on appeasing or releasing the evil spirit with medicinal formulas or trepa- Papyrus, it was not until Hippocrates that headaches were 5 classified as different types and attributed to real physical nation. pathological states.20 Later, the Egyptians and Babylonians both intro- Just as headache has been described for thousands duced the concepts of diagnosis, prognosis, and medical of years, the history of trepanation (earlier) and then of examination. The Ebers Papyrus (c. 1550 BC), which is craniotomy (later) can be traced back to prehistoric man. referred to as the oldest medical text, contains the first It is thought that the first cases of trepanation were most documented description of migraine headache, and pro- likely performed for religious or magical reasons, and poses surgical treatment for the condition (Fig. 2). In ad- later for treatment purposes to rid patients of conditions dition to the many incantations that were invoked against such as convulsive states, paresis, headaches, and, in par- migraine headaches and their accompanying symptoms ticular, traumatic lesions.23 However, many of the reasons such as nausea, trepanation was still practiced to release behind performing trepanation remain largely unknown the demons from the suffering heads.6 and undocumented, particularly their relationship to the treatment of headache. The Greco-Roman Period Surgical treatment of headache has evolved through- out history, and we will highlight in chronological order Ancient tales and folklore can be used as sources to the practice of craniotomy for the treatment of headache unmask mysteries surrounding the development of early in each historical era. medical knowledge, and we find one of the first descrip- Neurosurg Focus / Volume 36 / April 2014 1 Unauthenticated | Downloaded 10/03/21 10:42 PM UTC R. Assina, C. E. Sarris, and A. Mammis FIG. 1. Photograph of a trepanated skull of a female from the Neolith- ic Era. The trepanation defect shows new bone tissue growth, demon- strating that the patient survived the procedure. This skull is displayed in the Natural History Museum of Lausanne, Switzerland. tions of trepanation for treatment of headache told through FIG. 2. Photograph of the Ebers Papyrus, dated circa 1550 BC and Greek mythology (Fig. 3). Around 700 BC, it was said that known to be one of the oldest medical texts. It was found in Egypt in the the ancient Greek god Hephaestus had once performed 1870s and contains prescriptions written in hieroglyphics for more than 700 remedies for a wide variety of afflictions, along with early descrip- a craniotomy to relieve Zeus’s excruciating headache tions of the circulatory system. The papyrus is kept at the library of the caused by a mass growing inside his head (unbeknownst University of Leipzig in Germany. Image courtesy of the United States to Zeus, it was his daughter Athena).2 This classic story National Library of Medicine. of Athena’s birth, alleviating an unyielding headache by striking Zeus on the forehead with a double-headed axe to completely split the skull,10 emphasizes the rudimen- are hazardous treatments. You have to apply them when the headache persists after all that has been done… tary understanding of the development of headaches and the use of trepanation for their management2 (Fig. 4). It was not until the time of Hippocrates (460–370 BC) The Middle Ages (Fig. 5) that headache was first recognized as a symp- tom of a true disease rather than a spell from demons Whereas trepanation was frequently performed in or gods. Although in his work On Injuries of the Head the prehistoric and classical Greco-Roman eras, medical he describes and provides detailed instruction and clear treatments for headache were largely preferred during the warning of the dangers of trepanation, he does not men- Middle Ages by the Eastern, Arab, and Byzantine sur- tion its use in the treatment of headache.18 Later Hippo- geons. Trepanation was performed only in extraordinary cratic writers of Epidemics volumes IV and V circa 320 circumstances23 (Fig. 6). BC completed the list of reasons for trepanation, which Guy de Chauliac (AD 1300–1368) was one of the included headache in suspected cases of pus under the few to advocate trepanation for headache; he proposed skull.1 The late Hippocratic writers of the 3rd century the procedure to Pope Clement VI who at the time was 15 BC outlined distinct reasons for trepanation, including to suffering an unremitting headache. During this period, treat fractures and to remove dead bone; it is thought that however, treatments were largely focused on use of spe- headache was not specifically recorded as an indication cial solutions for compresses and ointments; surgical in- for trepanation because it was implicit in the symptom- terventions were rare (Fig. 7). atology of prior reasons.1 12 Later, as Koehler and van de Wiel recount, Aretae- The Renaissance Period us of Cappadocia (AD 30–90) in his Manual for the Treat- ment of Chronic Disease advocated reserving trepanation Because of the greater incidence in skull trauma for persistent severe headaches. during the Renaissance period due to the widespread Some physicians abrade or chisel the bone down to the dip- use of firearms, trepanation again became a common loe…. Others perforate the bone down to the meninges. These procedure.23 However, as knowledge of the anatomy and 2 Neurosurg Focus / Volume 36 / April 2014 Unauthenticated | Downloaded 10/03/21 10:42 PM UTC Craniotomy for headache FIG. 3. Photograph of a Greek black-figured lip cup from circa 540 BC. Artwork illustrates the birth of the goddess Athena from her father Zeus’s skull; the detail shows Hephaestus splitting Zeus’s skull with a two-headed axe. Image courtesy of the Trustees of the British Museum. physiology of the central nervous system rapidly expand- There remains yet another Chirurgical operation, extoll’d by ed during this era, various other remedies for headaches many for an obftinate Head-ach, but tried as yet by none (that I were used; trepanation remained reserved for intractable know) to wit, the opening of the Scull with a trepand Iron near the place of the pain: Our famous Harvey endeavour’d to per- cases. Prince Rupert of England underwent trepanation fwade a Lady of great quality to this, who was troubled with a in 1667 for severe, unyielding headache, and reportedly terrible and inveterate Head-ach, promifing her a Cure thereby; recovered very well after pus was drained from under his but neither fhe nor any other has been content to admit of the skull; his headache was alleviated that day.1 adminiftration: Truly it does not appear to me what certainty Thomas Willis (AD 1621–1675), considered by many we may expect from the Sculls being opened where it pains; if as the founder of clinical neuroscience, characterized nu- an Abfcefs lay hid there, this were the only way of Cure; but merous pathological states of the nervous system during that is wont to caufe the fleepy, or mortal Convulsive affects, his lifetime, including headache. In his chapter “Of the rather than to take away the Head-ach: if an inflamed Swelling, 24 or Puftules, or an Eryfiela has feized the Diploii, I know not Head-ach” in The London Practice of Physick, with in- whether thofe tumours expofed to the naked Air will evaporate creased understanding of the many mechanisms that can more eafily, or whether remedies applied to them, when bare, result in headache, Willis offered explanations of and in- will do anything or not: And in cafe the pains arife by reafon of structions for cure of many types of headaches.