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Thomas Jefferson used to get headaches. He did not get them very often- only once every ten years or so-but what they lacked in frequency they made up for in severity. Later in life he described the pain as excruciating, and we know that he suffered for days at a time, sometimes for weeks. These headaches incapacitated him and must have been a serious disruption in his busy life. Yet in his letters to his family he did little more than mention that he had "had an attack." He did not provide many details: perhaps his family was already so familiar with the situation that he did not need to elaborate. At any rate, Jefferson seems to have been resigned to his affliction and did not bemoan his fate. In his stoicism, he is typical of his era. Indeed, if we did not have medical literature to tell us otherwise, we might suppose that headaches were altogether rare events in the eighteenth and nineteenth centuries, so uncommon and so unenlightening are the references to them. But tucked away in footnotes and memoranda, in marginalia and perfunctory comments to friends and relatives, the headache is in fact revealed as an omnipresent and unpleasant condition, as common then as it is today. The only major difference is that Americans of earlier times simply did not complain much about them. Had they done so, however, they would have found an audience far more sympathetic than usually exists today. Although it was not thought to be as serious as so many of the other health problems of those days, the headache was nevertheless taken seriously. It was as real and as wretched as a toothache. No one accused Jefferson of pretending or exaggerating in order to avoid an obligation. When he said he had a bad headache, his friends and family believed him and sympathized.
By the twenty-first century, however, the situation had become somewhat different. Soon after World War I, the headache was at once more conspicuous and more ignominious. It began to be referred to casually in literature, in the movies, and eventually television. People now seem to grumble about their headaches all the time. In the United States alone there are said to be 45 million chronic sufferers (whose headaches occur more than fifteen days a month), and 25 to 30 million with migraines. Countless millions more have headaches only once in awhile but suffer enough to take time off work or to cancel a social engagement. Moreover, the word now has an additional meaning. Dwight D. Eisenhower, for example, had ileitis, bursitis, arthritis, and a couple of heart attacks, but the headaches he referred to in his diary were a wartime supply problem ("Ships! Ships! All we need is ships! . . . What a headache!") and a cold war diplomatic difficulty ("Monday I go to Turkey and Greece. More headaches and problems."). By the 1920s or thereabouts, the word headache had slipped into the American vernacular to refer to "something, such as a problem, that causes annoyance or trouble." The headache is now just a "pain in the neck," so to speak.
At about the same time, medical headaches began to be viewed with less sympathy and more suspicion, seen not as legitimate ailments but as the domain of whiners, malingerers, neurotics, and especially of frigid women. "Not tonight, dear, I've got a headache" has become a kind of mantra of the modern dysfunctional marriage. Consider John Steinbeck's pitiless description of Mrs. Bernice Pritchard in The Wayward Bus, published in 1948. She hated sex and resented her husband's advances, so to punish him she used headaches that were so bad "they twisted her face and reduced her to a panting, sweating, grinning, quivering blob of pain." She also used them to control her daughter. Steinbeck implies that Bernice either faked these migraines or deliberately conjured them but that in any case they were not quite "real." The daughter, at least, did not believe them. Her mother needed a psychiatrist, she thought, not a neurologist.
Bernice is an invented character, of course, but Steinbeck's attitude toward her headaches reflects more than his personal point of view or that of the general public. It also represents a position held at midcentury by many in the medical profession. By the 1950s, major and minor headaches alike were being described as the result of an inability to deal with the "resentments and dissatisfactions" that were a part of everyday life. People who got headaches brought them on themselves. The pain was real (although there were sometimes doubts even about this), but the solution was to learn to relax, or "grow up," or not be so self-centered. It was only a headache, after all. It would go away on its own.
In the 150 years between Jefferson and Steinbeck, the headache appears to have undergone a transformation, devolving from a respectable complaint into a somewhat disreputable cliché. But why did this happen? And why should anyone, least of all a historian, care? Headaches are hardly comparable to cancer or tuberculosis. They are certainly unpleasant; occasionally (as in brain tumors) they warn of a fatal outcome, and they have sometimes driven people to suicide, but in themselves they are not considered dangerous.
Yet headaches do in fact possess both medical and historical significance. As common, painful complaints encountered by all practitioners, they allow us a glimpse into the mundane medical events that most physicians had to deal with most of the time. They also demonstrate the challenges that "ordinary" ailments posed and can tell us something about medical imagination and innovation when faced with an ailment that, on the one hand, was run-of-the-mill but on the other was frustratingly protean. The only feature all headaches share, as it turns out, is the "ache." Beyond that, the pain can take myriad forms. It can be of any intensity, it can be located in any part of the head, occur at any interval, last for any length of time. Some headaches appear to be triggered by chocolate, others by fatigue, alcohol, sunshine, or a disagreeable smell. Any disease at all can be made infinitely more miserable by the presence of a headache, but they also occur on their own, spontaneously, without obvious precipitating factors. Their one virtue is that the majority are transient. Indeed, most are only moderately painful, short-lived, and occasional. Their variety, in fact, has meant that with the possible exception of migraine, a headache has never been considered to be a disease in itself: it has always been a symptom, a clue only, a sign of some deeper dysfunction. For much of the nineteenth century, at least, this ensured that headaches were never irrelevant.
In a medical philosophy derived from a holistic, constitutional, and often humoral view of disease, visible or reported symptoms of all kinds were invaluable diagnostic tools. The complicated art of interpreting these signs gave the physician an opportunity to exercise his particular skills and knowledge. As a prominent if perplexing symptom with many manifestations, the headache .t quite comfortably into this system. But this also meant that physicians were not inclined to use analgesics to treat it, because the goal of therapy was to get rid of the cause of the pain rather than the pain itself. Painkillers-that is, the opiates-were usually considered inappropriate.
By the early years of the twentieth century, advances in science had created an environment in which medical ideas were increasingly based on physical evidence-bacteria, blood pressure measurements, blood chemistry, and so on, supported by new diagnostic techniques. X-rays, for example, could now substantiate that in many painful conditions there was indeed something physically wrong with the part that hurt. Unfortunately, headaches produced no such visible or measurable features. They exhibited no tissue damage, no bruises, no bumps; they left no scars in the cranium, on the brain, or anywhere else. They were singularly uncooperative when it came to revealing why they hurt. Yet also around the turn of the century, advances in pharmaceutical chemistry introduced several new drugs such as aspirin that proved to be effective and relatively safe painkillers and became very popular as headache remedies-without shedding any light on the pathology of the headache or increasing the medical profession's understanding of the phenomenon. But because these new drugs could (and did) alleviate most ordinary headaches fairly quickly, in the twentieth century the headache was no longer a challenging piece of a diagnostic puzzle but simply an inconvenient and unpleasant experience for the patient and an annoying distraction for the doctor. Although not exactly thought to be irrelevant, the headache was now a "bother," just as many other inconvenient and unpleasant but not serious problems were now "headaches." Severe or chronic headaches, on the other hand, lacking physical confirmation of their existence and usually unaffected by the new drugs, now entered the realm of psychological disorders, and their sufferers began to be labeled as neurotic: "It's all in your head." Not surprisingly, headache victims did not always appreciate this attitude.