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Navigating Life
with Migraine
and Other Headaches
Lisa M. Shulman, MD
Editor-in-Chief, Neurology Now™ Books Series
Fellow of the American Academy of Neurology
Professor of Neurology
The Eugenia Brin Professor in Parkinson’s Disease and Movement Disorders
The Rosalyn Newman Distinguished Scholar in Parkinson’s Disease
Director, University of Maryland Parkinson’s Disease and Movement
Disorders Center
University of Maryland School of Medicine
Baltimore, MD
Other Titles in the Neurology Now™ Books Series

Navigating Life with Parkinson Disease
Sotirios A. Parashos, MD, PhD; Rose Wichmann, PT; and Todd Melby
Navigating Life with a Brain Tumor

Lynne P. Taylor, MD, FAAN; Alyx B. Porter Umphrey, MD; and Diane Richard
Navigating the Complexities of Stroke

Louis R. Caplan, MD, FAAN
Navigating Life with Multiple Sclerosis

Kathleen Costello, MS, ANP-BC, MSCN; Ben W. Thrower, MD;
and Barbara S. Giesser, MD
Navigating Life with Epilepsy

David C. Spencer, MD, FAAN
Navigating Life with Amyotrophic Lateral Sclerosis

Mark B. Bromberg, MD, PhD, FAAN, and Diane Banks Bromberg, JD
Navigating Life
with Migraine and
Other Headaches
William B. Young, MD, FAHS, FAAN
Thomas Jefferson University
Jefferson Hospital for Neuroscience
Philadelphia, PA
Stephen D. Silberstein, MD, FAHS,

FAAN, FACP
Thomas Jefferson University
Jefferson Hospital for Neuroscience
Philadelphia, PA
1
1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© American Academy of Neurology 2018
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Young, William B. (William Boyd), 1959– author. |
Silberstein, Stephen D., author. | American Academy of Neurology, issuing body.
Title: Navigating life with migraine and other headaches / by William B. Young
and Stephen D. Silberstein.
Other titles: Neurology now books.
Description: [Minneapolis, Minn.] : American Academy of Neurology ;
New York, NY : Oxford University Press, [2018] |
Series: Neurology now books | Includes index.
Identifiers: LCCN 2017009335 | ISBN 9780190640767 (paperback : alk. paper)
Subjects: | MESH: Headache Disorders—therapy | Migraine Disorders—therapy |
Popular Works
Classification: LCC RC392 | NLM WL 342 | DDC 616.8/4912—dc23
LC record available at https://lccn.loc.gov/2017009335
This material is not intended to be, and should not be considered, a substitute for
medical or other professional advice. Treatment for the conditions described in this
material is highly dependent on the individual circumstances. And, while this material
is designed to offer accurate information with respect to the subject matter covered
and to be current as of the time it was written, research and knowledge about medical
and health issues is constantly evolving and dose schedules for medications are being
revised continually, with new side effects recognized and accounted for regularly.
Readers must therefore always check the product information and clinical procedures
with the most up-to-date published product information and data sheets provided by
the manufacturers and the most recent codes of conduct and safety regulation. The
publisher and the authors make no representations or warranties to readers, express
or implied, as to the accuracy or completeness of this material. Without limiting the
foregoing, the publisher and the authors make no representations or warranties as to
the accuracy or efficacy of the drug dosages mentioned in the material. The authors
and the publisher do not accept, and expressly disclaim, any responsibility for any
liability, loss or risk that may be claimed or incurred as a consequence of the use and/or
application of any of the contents of this material.
1 3 5 7 9 8 6 4 2
Printed by Sheridan Books, Inc., United States of America
CONTENTS
About the AAN’s Neurology Now™ Books Series | xi

Lisa M. Shulman, MD, FAAN
Preface | xv
Section 1: Managing Your Headaches

1. Introduction: Why Headache Is So Important | 3
Just a Headache | 4
The Headache Experience | 5
Headache and Your Family | 6
Headache Has an Impact | 7
What You Can Do | 7
2. Pain, Disability, and Stigma in Persons with Headache | 9

What Is Stigma? | 10
What Is to Be Done About the Stigma? | 11
3. Classification and Diagnosis of Headache | 13

Your Headache History | 14
Clues for Diagnosing Your Headache | 14
Understanding Your Headache | 16
v
vi Contents
4. Managing Headaches | 17
What to Bring to Your First Headache Appointment | 17
What You May Do | 19
Your Doctor and You | 20
What We Think About Our Health Matters | 24
The Mind–Body Connection | 26
Family Relations | 26
Treatment Overview | 27
Examples of Headache Treatment Plans | 27
Is Your Doctor Skeptical About Your Headaches? | 27
How to Find a Good Headache Doctor | 28
Working with Your Insurance Company | 29
5. Headaches Requiring Urgent Medical Attention | 31

Aneurysm | 33
Subdural Hematoma | 33
Meningitis and Encephalitis | 34
Brain Tumor | 35
Hypertension | 36
Dissection | 37
Spinal Headache and Other Low-Pressure Headaches | 37
Section 2: Primary Headache Disorders

6. Migraine: Causes and Triggers | 41
Definitions | 41
Migraine without Aura | 42
Migraine with Aura | 44
Migraine with Brainstem Aura | 45
Contents v ii
The Cause of Migraine | 46

Migraine Throughout Life | 51
Migraine Symptoms | 51
Migraine Equivalents | 56
Migraine Triggers | 57
Menstrual Migraine and Other Hormonal Aspects
of Migraine | 57
Migraine Patterns (As They Relate to the Clock) | 58
Chronic Migraine | 59
7. Treating Migraine with Medication | 63

Migraine: Acute Medication | 64
Treat Early or Late | 72
Preventive Treatment | 72
Medications | 74
Special Circumstances | 77
8. Alternative and Behavioral Treatments for Migraine | 79

Alternative Therapies | 79
Dietary Treatments | 80
Physical Treatments | 82
Behavioral Therapies | 88
Psychotherapy | 92
Some Helpful Hints | 93
9. Migraine in Children | 95
How Headache Affects Children | 95
Evaluating Children Who Have Headaches | 96
Features of Migraine in Children | 97
v iii Contents
Special Forms of Childhood Migraine | 97

Secondary Headaches That Manifest in Children | 99
Preventing Migraine in Children | 100
Treating Acute Headache in Children | 101
10. Managing the Conditions that Often Coexist with

Migraine | 103
Comorbid Versus Coexistent Conditions | 103
Allergy | 104
Stroke and Heart Disease | 104
Epilepsy | 104
Obesity | 104
Pain | 105
Psychological Disturbances | 105
Raynaud’s Phenomenon and Autoimmune Disorders | 106
Restless Legs Syndrome | 106
Managing Comorbid Conditions | 107
11. Tension-Type Headache | 109

Causes of Tension-Type Headache | 110
When to Seek Help | 110
Treatment of Tension-Type Headache | 110
Managing Tension-Type Headache | 113
12. Cluster Headache | 115

Causes of Cluster Headache | 116
Cluster Headache Experience | 116
Cluster Headache Treatment | 117
Contents ix
13. Unusual Primary Headaches | 121

Unusual Headache Types | 121
Paroxysmal Hemicrania | 121
Chronic Daily Headache | 122
New Daily Persistent Headache | 122
Hemicrania Continua | 124
Ice Pick Headache | 125
Sexual Activity Headache | 126
Section 3: Secondary Headaches and Neuralgias

14. Sinus Headache and Nasal Disease | 131
Rhinosinusitis and Headache | 131
Cause of Rhinosinusitis | 132
Testing and Diagnosis | 132
Four Types of Rhinosinusitis | 133
Sinus Headache Treatment | 134
Confusing Migraine with “Sinus Headache” | 135
15. Disorders of the Neck | 137
Born That Way | 138
Got That Way | 140
Trauma | 140
Dystonia | 141
Diagnosis and Treatment | 141
x Contents
16. Post-Traumatic Headache | 145

Causes of Post-Traumatic Headache | 147
Treatment of Post-Traumatic Headache | 148
17. Trigeminal Neuralgia | 151
18. Atypical Facial Pain and Temporomandibular

Disorder | 155
Atypical Facial Pain | 155
Temporomandibular Disorder | 157
GLOSSARY | 161
A P P E N D I X 1 : T E S T S T H AT M AY H E L P PAT I E N T S W I T H
HE ADACHE | 169
A P P E N D I X 2 : R E S O U R C E S F O R PAT I E N T S W I T H
HE ADACHE DI SORDER S | 171
ABOU T T HE AMERIC AN AC ADEMY OF NEUROLOGY | 175
INDEX | 177
ABOUT THE AAN’S NEUROLOGY NOW™
BOOKS SERIES
Here is a question for you:

If you know more about your neurologic condition, will you do bet-
ter than if you know less?
Well, not simply optimism but hard data show that individu-
als who are more knowledgeable about their medical conditions do
have better outcomes. So learning about your neurologic condition
plays an important role in doing the very best you can. The main
purpose of both the Neurology Now™ Books series and Neurology
Now magazine from American Academy of Neurology (AAN) is to
focus on the needs of people with neurologic disorders. Our goal is
to view neurologic issues through the eyes of people with neurologic
problems in order to understand and respond to their practical day-
to-day needs.
So, you are probably saying, “Of course, knowledge is a good
thing, but how can it change the course of my disease?” Well, health
care is really a two-way street. After you have had a stroke, you
need to find a knowledgeable and trusted neurologist; however,
no physician can overcome the obstacle of working with inaccurate
or incomplete information. Your physician is working to navigate
the clues you provide in your own words combined with the clues
from their neurologic examination in order to arrive at an accurate
xi
x ii ABOUT NEUROLOGY NOW BOOKS
diagnosis and respond to your individual needs. Many types of

important clues exist, such as your description of your symptoms or
your ability to identify how your neurologic condition affects your
daily activities.
Poor patient-physician communication inevitably results in
less-than-ideal outcomes. This problem is well described by the old
adage, “garbage in, garbage out.” The better you pin down and com-
municate your main problem(s), the more likely you are to walk
out of your doctor’s office with the plan that is right for you. Your
neurologist is the expert in your disorder, but you and your family
are the experts in you. Physician decision making is not a “one shoe
fits all” enterprise, yet when accurate, individualized information is
lacking, that’s what it becomes.
Whether you are startled by hearing a new diagnosis or you
come to this knowledge gradually, learning that you have a neu-
rologic problem is jarring. Many neurologic disorders are chronic;
you aren’t simply adjusting to something new—you will need to
deal with this disorder for the foreseeable future. In certain ways,
life has changed. Now, there are two crucial “next steps”: the first
is finding good neurologic care for your problem, and the second
is successfully adjusting to living with your condition. This second
step depends on attaining knowledge of your condition, learning
new skills to manage the condition, and finding the flexibility and
resourcefulness to restore your quality of life. When successful, you
regain your equilibrium and restore a sense of confidence and con-
trol that is the cornerstone of well-being.
When healthy adjustment does not occur following a new diag-
nosis, a sense of feeling out of control and overwhelmed often per-
sists, and no doctor’s prescription will adequately respond to this
problem. Individuals who acquire good self-management skills are
often able to recognize and understand new symptoms and take
appropriate action. Conversely, those who are lacking in confidence
may respond to the same symptom with a growing sense of anx-
iety and urgency. In the first case, “watchful waiting” or a call to
About Neurolog y Now Books x iii
the physician may result in resolution of the problem. In the second

case, the uncertainty and anxiety often lead to multiple physician
consultations, unnecessary new prescriptions, social withdrawal, or
unwarranted hospitalization. Outcomes can be dramatically differ-
ent depending on knowledge and preparedness.
Managing a neurologic disorder is new territory, and you should
not be surprised that you need to be equipped with new informa-
tion and a new skill set to effectively manage your condition. You
will need to learn new words that describe both your symptoms
and their treatment to communicate effectively with the members
of your medical team. You will also need to learn how to gather
accurate information about your condition when you need it and
to avoid misinformation. Although all of your physicians document
your progress in their medical records, keeping a personal journal
about your neurologic condition will help you summarize and track
all your medical information in one place. When you bring this
journal with you as you go to see your physician, you will be able to
provide more accurate information about your history and previ-
ous treatment. Your active and informed involvement in your care
and decision making results in a better quality of care and better
outcomes.
Your neurologic condition is likely to pose new challenges in
daily activities, including interactions in your family, your work-
place, and your social and recreational activities. How can you best
manage your symptoms or your medication dosing schedule in the
context of your normal activities? When should you disclose your
diagnosis to others? Neurology Now™ Books provide you with the
background you need, including the experiences of others who have
faced similar problems, to guide you through this unfamiliar terrain.
Our goal is to give you the resources you need to “take your doc-
tor with you” when you confront these new challenges. We are com-
mitted to answering the questions and concerns of individuals living
with neurologic disorders and their families in each volume of the
Neurology Now™ Books series. We want you to be as prepared and
x iv ABOUT NEUROLOGY NOW BOOKS
confident as possible to participate with your doctors in your medi-

cal care. Much care is taken to develop each book with you in mind.
We include the most up- to-
date, informative, and useful
answers to the questions that most concern you—whether you
find yourself in the unexpected role of patient or caregiver. Real-
life experiences of patients and families are found throughout
the text to illustrate important points. And feedback based on
correspondence from Neurology Now magazine readers informs
topics for new books and is integral to our quality improvement.
These features are found in all books in the Neurology Now™ Books
series so that you can expect the same quality and patient-cen-
tered approach in every volume.
I hope that you have arrived at a new understanding of why
“knowledge is empowering” when it comes to your medical care and
that Neurology Now™ Books will serve as an important foundation
for the new skills you need to be effective in managing a neurologic
condition.
Lisa M. Shulman, MD, FAAN
Editor-in-Chief, Neurology Now™ Books Series
Fellow of the American Academy of Neurology
The Eugenia Brin Professor in Parkinson’s Disease
and Movement Disorders
The Rosalyn Newman Distinguished Scholar
in Parkinson’s Disease
Director, University of Maryland Parkinson’s Disease and
Movement Disorders Center
University of Maryland School of Medicine
PREFACE
Navigating Life with Migraine and Other Headaches is written for

those who have migraine and other headache types, their family
members, and their caregivers. We have tried to write this guide in
an approachable manner to give you a bit of background and under-
standing on what causes headaches and to address many of the
questions that we frequently hear. We may not cover everything,
but we hope this will be an informed start for everyone affected by
headache.
This updated edition begins with a general overview and a dis-
cussion of causes. Did you know that Julius Caesar, Napoleon,
Thomas Jefferson, Charles Darwin, Sigmund Freud, Vincent van
Gogh, Pablo Picasso, and many other famous people had migraine?
You’re not alone! We’ve been trying to understand and treat head-
ache for thousands of years.
Different types of headache are thoroughly explained in easy-to-
understand language, beginning with migraine, which is the most
common type of severe headache that can occur at any age. In chil
dren, it is more common in boys, but after puberty, it is much more
common in girls. Even very young children are suspected of having
migraine, although diagnosing them is almost impossible until they
learn to speak. In women, it is most common between ages 40 and
xv
xvi P reface
45, while men tend to have migraine at a slightly younger age. This
means that it often strikes people in their most economically pro-
ductive years, which is a big part of the effect that migraine has on
society.
We have included specific information about the different
types of migraine: migraine without aura (previously called common
migraine), migraine with aura, and other migraine types. Emphasis
is placed on the necessity of early treatment, the importance of
understanding the difference between a headache cause and a head-
ache trigger, and how to avoid common triggers. Rebound headache,
caused by the overuse of acute medication, is also a topic of special
significance that is discussed in detail.
In addition to migraine, the book contains a chapter on ten-
sion-type headache, the most common primary headache disorder;
80 percent of us will have a tension-type headache at some time in
our lives. Chapters describing cluster headache, unusual headaches,
nonheadache illnesses that frequently accompany headache, sinus
headache, disorders of the neck, post-traumatic headache, and atyp-
ical facial pain and trigeminal neuralgia are also included.
Treatment options for all types of headache are thoroughly dis-
cussed, including the treatment of migraine with medications that
can be taken daily to help prevent headache, stop headache pain once
it has begun, and prevent worsening of headaches. Different people
have different responses to both prescription and nonprescription
medications, so we cover this important topic as well. Managing
your headache pain goes beyond simply popping pills; therefore,
lifestyle issues are considered, including the possibility of depres-
sion or other psychological factors and family relationships. We’ve
included information about alternative therapies, such as vitamins
and herbal supplements, physical therapy, acupressure, massage,
acupuncture, chiropractic care, craniosacral therapy, hydrotherapy,
and yoga, as well as behavioral treatments, such as stress-manage-
ment training and psychotherapy.
Preface x v ii
We hope that Navigating Life with Migraine and Other

Headaches will help individuals with headaches, and those who
care for them, to gain a deeper understanding of what is known
about headache and what is not known, allowing them to explore
diagnosis and treatment with this knowledge in hand. We are at
the threshold of an explosion in the understanding, diagnosis,
and treatment of migraine and other headaches, and soon more
answers will be found.
William B. Young, MD, FAHS, FAAN
Stephen D. Silberstein, MD, FAHS, FAAN, FACP
Navigating Life
with Migraine
and Other Headaches
Section 1
Managing Your Headaches

Chapter 1
Introduction
Why Headache Is So Important
In this chapter, you’ll learn:
• The scope of migraine as a public health problem

• How migraine (or chronic severe headache) affects quality
of life
While driving home from work, Kathy was distracted by spar-

kling lights just to the left of her field of vision. When she turned
to see what caused them, they moved away. She shook her head
as if to shake them loose, and for a moment they disappeared.
Within seconds, spears of bright light punctured the left side of
her vision, too dramatic to ignore, and a tingling numbness ran
up her left arm. She was concerned, but not frightened, until she
looked down at the dashboard and couldn’t read it because of a
blurry patch in the center of her vision. She lived alone and had
no one to call, so she turned left instead of right, and headed for
the emergency department, tortured by fears of a brain tumor
or some other medical horror. As she pulled into the hospital
entrance, a stabbing pain seared through her left eye.
“You had a migraine,” the neurologist told her, hours later,
as she lay on the uncomfortable emergency department gur-
ney, exhausted but finally, mercifully, pain free.
“All that from just a headache?” (Figure 1.1.)
3
4 N avigating L ife with M igraine & H eadaches
FIGU R E 1 .1 A patient’s illustration of the migraine aura.

Reproduced from Wilkinson M, Robinson D. Migraine art. Cephalalgia
1985;5:151–157.
Just a Headache
How often have you heard that phrase? Headache is such a com-
mon symptom that it often goes overlooked, undertreated, over-
treated, or untreated. Actually, fewer people escape headache than
experience a headache at least once in their lives. Although most
people never see a doctor for their headaches, headache is the most
common symptom for which patients see neurologists, and the sev-
enth most common symptom for which they visit their primary care
providers.
The impact of headache should not be taken lightly. Among
chronic disorders, it is the third most common cause of missed
work. It can affect you at home, at work, and in your interactions
with friends and family members. It interferes with recreation,
exercise, and the pleasures of everyday living.
1. Introduction 5
Still, most people with headache self-treat or even ignore their

headaches. Even people with migraine tend to put off seeking med-
ical care. Despite the often-severe pain and other severely uncom-
fortable symptoms associated with migraine, reportedly less than
half of sufferers consult a doctor for their problem. The reasons for
this are many. Widespread misconceptions about headaches per-
sist. Many people believe that “nothing can really be done” or that
it is somehow weak to see a doctor for “just a headache.”
In many ways, Kathy was fortunate. The odds of obtaining such
speedy relief of symptoms are typically against a person experi-
encing migraine. The visual disturbances that startled her served
as a warning, even more than the pain that followed, and led her
to seek immediate help at an emergency department. Most people
who have migraine do not experience an aura (see Chapter 3), the
sparkling lights, numbness and tingling, and blurred vision that
Kathy experienced. Still, many people, including some doctors,
believe that without these symptoms, a headache cannot truly
be called a migraine. When Kathy described her symptoms to the
treating physician, she was referred to a neurologist. She was for-
tunate that the neurologist who treated her was knowledgeable
about migraine and the latest treatments and that she was treated
appropriately. She was also fortunate that she responded well to
treatment. Even the newest and most appropriate treatment will
not be effective in every case. The chapters in this book are aimed
to guide you in your quest for better management and treatment
of your headaches.
The Headache Experience
Greg thought his head was going to explode. A construction

worker, he was a tall, heavily built man, attractive, with curly
brown hair and hazel eyes. He was well liked and would often
(Continued)
(Continued)
cover for his coworkers. That was the reason he did not lose his
job when he repeatedly called in sick. “A headache?” his coworker
asked sarcastically when the foreman announced that once
again they’d be short a man. “Jeez, Rob, we all get headaches!”
He rolled his eyes. “This is the second day this week!”
“I don’t know, Bill. Miriam said he was acting weird, pacing
around the house, can’t sit still. She’s trying to get him to
the doctor, but you know him—he won’t go. She says she’s
worried, that one side of his face is all goofy. She thinks he’s
having a stroke or something.”
Headaches can make you feel miserable. The quality of life for
those with chronic severe headaches is very poor compared with
that of people who have other disorders. Many, but not all, peo-
ple with migraine have an extremely poor quality of life. Frequent
absences from work and the inability to participate in many fam-
ily and social activities are evidence of the extraordinarily nega-
tive impact that headache can have on your life. The significant
decrease in your quality of life may even be severe enough to
prompt you to seek care at a specialty headache center.
Headache and Your Family
“Be quiet, kids! Your mother has one of her headaches.” From
her bedroom, Angela heard her husband’s voice in the hall.
She had migraine attacks 2 or 3 days per month ever since she
reached puberty. Every month her husband would darken the
bedroom where she lay, keep the kids out of trouble and away
from her, cook the meals, and run the house. He was a gem,
her friends all told her. She was the luckiest woman on earth; if
only she could feel well and enjoy it.
1. Introduction 7
Headache Has an Impact
Migraine is a public health problem of enormous scope. Twenty-

eight million U.S. residents have severe migraine. Of the people
who have migraine, 25 percent have four or more severe attacks a
month, 35 percent experience one to four severe attacks a month,
and 40 percent experience less than one severe attack a month.
Additionally, about 30 percent are severely disabled or need bed
rest. Migraine is a lifelong disorder, but it may improve or worsen
over time. Headache not only affects the person with headache, but
it can also negatively affect family and friends. You may worry that
at any time an attack will disrupt your ability to work, to care for
your family, or to engage in social activities. Additionally, migraine
is a condition that can have significant financial impact on you, your
family, and your employer.
Headache has consequences on society. Inappropriate evalu-
ation and treatment of migraine puts an enormous burden on an
already overloaded health care delivery system. Migraine that is
not correctly diagnosed and treated often results in an excessive
number of unnecessary doctor office visits; frequent inappropriate
emergency department visits; the overuse of unneeded and some-
times frighteningly sophisticated medical tests, such as magnetic
resonance imagings (MRIs) and computed tomography (CT) scans;
and the financial burden of purchasing inappropriate—and some-
times harmful—over-the-counter and prescription medications.
What You Can Do
Most of us who experience headache can be safely and effectively

evaluated and appropriately treated by a headache specialist who
has taken a detailed medical history and completed a thorough
physical examination. The use of MRIs and CT scans is occasionally
necessary for the proper diagnosis of a small number of headache
patients. In other words, the time lost from healthy living, the
absence from work, the expensive tests and inappropriate medica-
tions, and, in some cases, the resulting disability migraine causes
are largely unnecessary and can be avoided with the proper tools
and resources to manage your care!
Chapter 2
Pain, Disability, and Stigma

in Persons with Headache
• That disparity exists between care and funding for headache

compared to other neurologic disorders
• How disability associated with headache is underestimated
and misunderstood
• How headache patients may be stigmatized by family, friends,
colleagues, and even doctors
• How to help battle the stigma associated with headache
through involvement in community action groups
Individuals with migraine rate their pain as severe or very severe

almost two-thirds of the time. As discussed in Chapter 1, roughly
2 percent of the population has chronic migraine, and migraine
is the seventh leading cause of medical disability, as measured in
years of healthy living lost to disability. Additionally, migraine may
have associated symptoms that headache patients find disabling,
including nausea, vomiting, light and sound sensitivity, intoler-
ance to motion and exertion, dizziness, and fatigue. The headache,
accompanying symptoms, and resultant disability cause migraine to
be one of the leading causes of days when patients cannot function
fully at home, at work, or in society in general. Still, people with
migraine are made to feel that it is unacceptable for them to take
time off from their responsibilities. While people with migraine
9
generally struggle through most of their attacks, it is common for

migraine to affect work, self-care, and social and family life, com-
pletely transforming the type of life that headache patients can live.
In the United States, no criteria exist for migraine-related dis-
ability, despite the fact that specific criteria for neurologic disabil-
ity exist for diseases with much lower impact, such as epilepsy.
Appropriate evaluation by a headache specialist and treatment with
lifestyle changes and medications that decrease, stop, or prevent
headache pain greatly affect the patient’s quality of life and ability
to participate in family, work-related, and social activities.
What Is Stigma?
Stigma is the perception of a person’s being less worthy than friends

and colleagues, and stigma can mean the person is treated unfairly
because of negative feelings toward people with the disease or con-
dition. This devaluation of a patient’s worth often is internalized
by the patient, with resultant loss of self-esteem, confidence, and
productivity.
Tiffany has had near-daily migraine for 10 months. She has

been given six different prescription medicines from two dif-
ferent specialists and still missed work on seven different days
because she was vomiting and could not get out of bed. Her boss
has mentioned that he has “concern” about her attendance.
The lack of attention to the disability of headache patients

and the societal cost of headache cause the medical commu
nity to underestimate the significance of headache disorders as a
life-altering disease with a high rate of associated disability. The
National Institutes of Health funds migraine research at a level
well below what would be dictated by its impact on medical costs,
2. Pain, Disability, and Stigma in Persons with Headache 11
societal costs, and personal pain and disability. In fact, migraine

and cluster headache (see Chapter 12) are the least funded of all
neurologic diseases. Academic medical centers usually offer very
little for patients with migraine, while they compete for the can-
cer patient, the stroke patient, and the dementia patient. When
institutions are rated for their quality of neurologic care, they are
expected to have a dementia center, a stroke center, a multiple scle-
rosis center, but never a headache center.
Doctors’ prejudices can also stigmatize patients. Patients
may feel their doctors do not recognize the legitimacy of their
disease, sending subtle messages of disapproval. If a treatment
fails, patients may feel blamed in a way that they would not if an
antibiotic or chemotherapy failed. Some headache doctors have
said that they do not believe anyone should be given disability for
migraine, although loss of job due to migraine is not rare. People
with chronic headache disorders are often heroic, carving out
their best possible lives even if treatment has not been success-
ful, and when work, friends, and family just do not understand.
Having the confidence that you are coping in a brave and reason-
able way can change your own perception of yourself and others’
perceptions of you.
What Is to Be Done About the Stigma?
It is important for physicians, other medical personnel, hospital and

insurance administrators, and laypeople to recognize the harm done
by underestimating the pain, disability, and costs of inappropriately
diagnosed and treated headache disorders. Prejudices against peo-
ple with migraine who miss work, lose jobs, or fail to meet someone
else’s social expectations negatively impact the self-esteem, produc-
tivity, and social contributions of millions of headache patients. The
medical and societal costs dictate more attention to migraine as a
chronic disease and the need for funding of research and treatment
centers. The good news is that government agencies, such as the

National Institutes of Health, and professional organizations, such
as the American Academy of Neurology and the American Headache
Society, are working to overcome the negative perceptions of head-
ache disorders.
A second important step toward getting understanding of head-
ache and its treatment and having a positive impact on your com-
munity requires active involvement. Don’t feel stigmatized. History
shows us that disease-related stigma can be reversed when a com-
munity of patients comes together to raise awareness and funding
for their cause. If you or someone you know has severe headache or
migraine, here are some headache organizations that you can con-
sider supporting:
• Miles for Migraine

• Runnin’ for Research
• 36 Million Migraine Campaign/American Migraine
Foundation
• Migraine Research Foundation
• Clusterbusters®
• Alliance for Headache Disorders Advocacy
• American Headache and Migraine Association
Chapter 3
Classification and Diagnosis of Headache
• How primary and secondary headache types differ

• The importance of your headache history
• How the type of pain and other symptoms can help diagnose
your headache type
Headache has many causes. It can be a primary headache, such

as tension-type headache or migraine, meaning that the head-
ache itself is the main medical problem. It can also be a secondary
headache, a headache that is the result of an underlying medical
condition, such as a neck injury or a sinus infection. Headache is
rarely, however, the first sign of a dangerous medical condition (see
Chapter 5).
Most headache patients have normal medical and neurologic
examinations. When and how your headaches began provide impor-
tant clues for diagnosis. Primary headaches usually begin in child-
hood or early adult life. However, if your headaches begins after the
age of 55 years, a serious disorder is more likely. A headache that
begins after a head injury suggests a postconcussive headache dis-
order or intracranial pathology, although head trauma may trig-
ger both migraine and cluster headache. Fever in association with
the onset of headache suggests an infectious cause. Exertion (e.g.,
weight lifting) may cause a harmless exertional headache, or it
can precipitate a subarachnoid hemorrhage, an emergent type of
stroke caused by bleeding into the space surrounding the brain.
13
Your Headache History
Where your head pain is located and the way it spreads help your doc-
tor to make a diagnosis, because many headaches follow typical pain
patterns. A unilateral, or one-sided, headache suggests migraine or
cluster headache. Cluster headaches are always unilateral, with the
pain centered in or around the eye. Headache of migraine can be
on one or both sides of the head. On the other hand, tension-type
headache pain is typically bilateral, and trigeminal neuralgia may
cause pain in any area of the face.
Pain duration and other symptoms also provide clues for diag-
nosis. Migraine is typically throbbing, aggravated by movement,
and associated with nausea, photophobia, and phonophobia (see
below). It typically lasts from 4 to 72 hours. Cluster headaches usu-
ally last an average of 15 minutes to 3 hours. Episodic tension-type
headaches (see Chapter 11) are typically dull and milder in inten-
sity and tend to last from 30 minutes to 7 days. Understanding
where your head pain occurs and how long it lasts is instrumental
in helping your doctor diagnose—and ultimately treat—your head-
ache condition (Table 3.1).
Clues for Diagnosing Your Headache
How often do your attacks occur, and what is the longest headache-
free period you’ve experienced in the last 6 months?
• Migraine attacks may occur at random or in association with

the menstrual cycle, on weekends, on vacation, or upon
relaxing after stress.
• Episodic cluster headaches typically occur in a regular
pattern. During the cluster period, which usually lasts
between 2 weeks and 6 months, headaches may occur as
rarely as once every other day or as often as eight times a day.
3. Classification and Diagnosis of Headache 15
TA BL E 3 .1 Migraine or Tension-Type Headache
Characteristics Migraine Tension-type headache
Frequency Variable Variable

Duration 4–72 hours 30 minutes–7 days
Location Unilateral (40% Bilateral
bilateral)
Description Pulsating Pressing/tightening
Intensity Moderate–severe Mild–moderate
Worse with physical Yes No
activity
Nausea or vomiting Yes No
Photophobia Yes No
or phonophobia
Aura Yes (20%) No
The attacks tend to recur at similar times of the day or night,

and often wake the person during sleep.
• Episodic tension-type headaches occur fewer than 15 times
a month. If they occur more frequently, they are classified as
chronic tension-type headaches.
• Headaches of very sudden onset are worrisome. The
headache of subarachnoid hemorrhage or pituitary apoplexy,
both neurologic emergencies, typically have a sudden,
explosive onset.
Pain is also a distinguishing feature:
• Migraine pain is characteristically throbbing or pulsating.

• Cluster headache pain is deep, boring, or piercing. It is
sometimes likened to having a red-hot poker thrust into
the eye.
• Tension-type headache pain feels like a tight band or vise

around the head, and it can be mild to moderate in intensity.
When you get your headache, do other features come before, dur-
ing, or after the pain? Do you experience other notable symptoms?
• Photophobia is an unusual or heightened sensitivity to light

during a headache attack.
• Phonophobia is an unusual or heightened sensitivity to noise.
• Osmophobia is a heightened sensitivity to odors.
• Aura is a sensory perception (warning sign) before, or even
during, a headache. It can be as mundane as tiny floaters in
front of your eyes or as dramatic as hallucinations. The aura
normally lasts about 20 minutes.
Understanding Your Headache
Headache has many causes. Most headaches are primary headaches,

especially tension-type headache or migraine. Much less commonly,
the headache is a secondary headache, due to an underlying medical
condition, such as a neck injury or a sinus infection. Some people
seek medical attention primarily because they are concerned that
the headache is due to a serious underlying disease. MRIs and CT
scans are rarely needed. However, more often, people seeking med-
ical attention have severe pain and disability and require a program
of care for improving their lives. Making sense of your headache his-
tory is the key to your diagnosis and treatment plan.
Chapter 4
Managing Headaches
• What to bring to your first headache appointment

• What expectations of treatment are realistic
• How to partner with your doctor to treat your headache
• How to find a headache specialist
• How to work with your insurance company
What to Bring to Your First Headache Appointment
Doctor (to colleague): “This patient never does what I suggest.”

Patient (to friend): “The doctor just doesn’t understand or care.”
If you have a burst appendix, your physician must take charge and
direct treatment, and you take on a more passive role until it is
time to recuperate. Headache treatment should not be like this.
Headache treatment should be a two-way street, with you commu-
nicating your goals and desires regarding your headache manage-
ment and your doctor bringing medical expertise and expectations,
and both of you together developing a final treatment plan that
incorporates both perspectives.
You may arrive at the doctor’s office expecting an immediate
diagnosis and rapid treatment and cure. Our recommendation
is to have more realistic expectations. Diagnosing—and more
important—treating your headache can take awhile, so be patient
17
and work with your doctor for the best outcome. A patient may
say, “I spent all day there. I had a bunch of tests, I filled out a gazil-
lion forms, and I don’t feel any better!” Headache control takes
time, and sometimes a good deal of trial and error. Tests will not
make you feel better, but they will help the doctor figure out how
to do so.
Part of the responsibility of a conscientious caregiver is to help
you understand your headache by clarifying the problem while lay-
ing the groundwork for the job ahead. Your doctor or nurse should
teach you what you need to know to be able to manage your head-
ache safely and effectively at home. Your doctor may not—in fact,
should not—try to explain everything at once. It is almost impossi-
ble to retain information if too much is given to you in a single visit.
The information that may be explained to you early in your course
of treatment (in the first or second visit) includes:
• The difference between primary headache and secondary

headache
• The difference between a benign and an ominous headache
• The difference between a trigger and a cause of headache
• The type of headache you have and its biological basis
If you have a primary headache disorder, such as migraine, you

need to know that limited testing will stop and treatment will begin.
People with primary headaches often search endlessly for a cause of
their headaches and end up dissatisfied. Once the testing is com-
pleted and no secondary headache is found, it is best to accept the
fact that the headache is a primary one and cannot be cured. If it is
a primary headache disorder, blame and anger are not helpful and
can actually worsen your headache. You and your doctor need to roll
up your sleeves and get to work, because while treatment may be
simple and effective, it could require many trials before a suitable
solution is found.
4. Managing Headaches 19
What You May Do
A necessary first step may be stopping overused pain medication.

Patients with daily headaches often become upset when doctors
make this suggestion. Patients may believe that the doctor thinks
they are addicted, but there is a big difference between addiction
and medication overuse. Sometimes, overuse results in what is
called rebound headache, a headache caused by overusing over-the-
counter pain medication. Addicts are usually trying to escape from
society or emotional pain. In contrast, patients who are “rebound-
ing” want to take care of their families, do their jobs, and be part of
society. Thus, they begin the vicious cycle of taking more and more
medicine to continue functioning. Rebounders must understand
that even if their motivations are excellent, rebound is an unhealthy
behavior. No matter how noble the reasons, rebound must stop.
Establish realistic goals: if you want your severe headache to be
gone in 5 minutes, and you are dissatisfied with anything that works
more slowly, you will probably never be satisfied. Once a migraine
is moderate or severe, the best oral treatments have a one in seven
chance of relief at 30 minutes and a three in five chance of relief at
2 hours. That means that six out of seven patients do not have relief
at 30 minutes, and a much smaller proportion of them are actually
pain-free at 30 minutes. Outcomes improve greatly if the headache
is treated in the mild stage or if an injection is used (see Chapter 7).
Also, no medicine will work every single time. For some people,
treatment will be successful 95 percent of the time, for others, 80
percent of the time, and a few unlucky people may find that the best
they can get is a treatment that works half the time.
Try to establish realistic expectations about side effects for both
acute treatment (which stops a headache) and preventive treat-
ment (which keeps headaches from occurring). Most headache
medicines have side effects that depend on the medication used
(see Chapter 7). You may have to tolerate side effects and work to
minimize them. The doctor can choose medicines that have fewer or
less bothersome side effects for you or even side effects that provide
some benefit; for example, a physician might choose a medicine that
would cause nighttime sleepiness for someone with insomnia.
If you have a primary headache, your headaches may be controlled
and may even stop. In studies of preventive medication, only half of
subjects get 50 percent or more relief from their headaches with the
first drug they try. Some doctors often do better than this by individu-
alizing treatment, but they may need to try several preventives. With
preventive treatment, headache improvement may not be immedi-
ate; it usually begins in about 4 weeks and generally it takes about 8
weeks to know if the preventive treatment is fully effective. You may
be asked to tolerate some side effects. To minimize dissatisfaction,
you and your doctor can use helpful strategies, such as once-a-day
dosing and medicating before bed if sleepiness or other side effects
could be caused by the treatment. So do not give up. Old treatments
often work, and new treatments are constantly being developed.
Your Doctor and You
You should make your preferences known to your doctor. For exam-
ple, your worst headaches might only be treatable at the cost of
sleepiness. Maybe you would prefer to bear the pain and stay awake;
maybe you would prefer less pain and some sleepiness. Some people
will take the pain and not the medicine, while others will accept the
side effects to obtain the benefit. The doctor-patient relationship is
a partnership. Family members can be helpful, but they are not crit-
ical members of the treatment partnership. The doctor will, as much
as possible, deal principally with you, not your spouse, mother-
in-law, or concerned neighbor. Interested family members may be
invited—by you—into the doctor’s office and allowed to ask a few
questions, but it is usually inappropriate for them to give most of
the history or answer most of the questions. (Obviously, this does
not apply when the patient is a young child or is mentally or psycho-

logically incapacitated.)
Take charge of your care as much as possible. Know your medi-
cines, including how often you take them. Understand the parts of
your treatment plan that do not use medicines and how to imple-
ment those therapies. This helps to simplify treatment and puts you
in charge of your own health and life.
To improve the partnership, help your doctor by being prepared
to answer the basic questions he or she needs to know to adjust
your treatment. Your doctor needs to know how often you have
headaches, how long they last, and the intensity of your pain. Other
questions might include:
• When did you first start having headaches?

• Have your headaches changed?
• When do your headaches occur (e.g., time of day, before or
during menstrual cycle)?
• Do your headaches come and go?
• How long does a headache usually last?
• Do you have a headache virtually every day?
• Are you ever pain free?
• Where do you feel pain—on one side of your head, on both
sides, behind one eye, in the front of your head? Does the
pain move from one spot to another?
• Does the pain creep up and get worse, or does it start
suddenly?
• How does the pain feel—dull ache, throbbing, mild, or
excruciating?
• What other symptoms do you have with your headaches?
• Do you feel nauseated or vomit?
• Do you have sensitivity to lights or sounds?
• Do you have visual symptoms or numbness before or
during the headache?
• Do you get any warning symptoms of a headache?
• What medications have you tried, and did these provide any
relief at all?
• Do you take any vitamin or herbal supplements?
• Do you get a headache when you skip meals or eat
certain foods?
• Do your headaches follow physical activity, such as having sex
or exercising?
• Have you noticed a connection between extreme stress and
the start of a headache?
• Have you noticed anything that seems to make the pain
worse when you have a headache?
• Have you had any kind of head trauma—a car accident or
sports injury, for example?
• Do others in your family have headaches?
You should prepare for these questions and be ready to answer

them to the best of your ability. Many patients find that keeping a
headache calendar helps when trying to answer these questions.
You must be honest about the extent of your headache disability
and medication use! It is absolutely vital to eliminate confusion, so
don’t keep secrets from your doctor. Your doctor may use a stan-
dardized questionnaire, such as the Migraine Disability Assessment
(MIDAS), to help determine the impact your headaches have on
your life (Figure 4.1).
What does the MIDAS questionnaire tell your doctor? Referring
to Figure 4.1, first add up your answers to questions 1 through 5. If
the total is 5 or less, you have minimal or infrequent disability, often
with low treatment needs. However, if you have infrequent, but severe
and disabling headaches, you may benefit from aggressive treatment.
If the total is 6 to 10, you have mild or infrequent disability and have
moderate treatment needs. If the total score is 11 to 20, you have mod-
erate disability and have urgent treatment needs. Finally, if the total
is 21, you have severe disability and very urgent treatment needs. If
F IGU R E 4 .1 Migraine Disability Assessment (MIDAS). Reproduced

from Stewart W, Lipton R, Dowson A, Sawyer J. Development and testing
of the Migraine Disability Assessment (MIDAS) Questionnaire to assess
headache-related disability. Neurology 2001;56(Suppl. 1): S20–S28.
doi: http://dx.doi.org/10.1212/WNL.56.suppl_1.S20
you fill out the MIDAS questionnaire and your score is greater than 5,
you should see a physician. If your job is at risk due to headaches, some
very aggressive treatments may be reasonable, and this type of ques-
tionnaire encourages these important discussions.
To appropriately discuss the effects of medications, you need to
understand the difference between an acute medicine (which stops a
headache) and a preventive medicine (which keeps headaches from
occurring). You should know the limits of how much of your acute
medication to take to prevent rebound; if you are treating a head-
ache with medicine every day, eventually the headache problem is
likely to become much worse.
What We Think About Our Health Matters
People look at their own health in terms of three areas of control,

or things that determine their health. One is the extent to which
the doctor is in control, the second is the extent to which you con-
trol your own health and take responsibility for lifestyle changes
that will improve your outcomes, and the third is the extent to
which random, chaotic factors affect your health. All three factors
are important. Patients who view their health as principally deter-
mined by the doctor or by chance do not do as well as those who
have a more balanced view of the concept of shared control, and of
the concept of individual responsibility for being compliant with all
medications, lifestyle changes, and regular follow-up visits as sug-
gested by their doctor.
Patients with headache need structure and balance. For many
headache patients, a structured world without extremes or variabil-
ity is the ideal. You can control stress, but it is not realistic to expect
to eliminate it completely. Exercise regularly, or try to. Moderate
food and alcohol intake and make sure that each day includes pleas
urable activities; in general, strive to have a balanced lifestyle.
Practice some form of stress-reducing technique daily, such as med-
itation, journaling, breathing exercises, or yoga (see Chapter 8).
These measures can guide you toward a less stressful lifestyle or
at least help you move in that general direction. You have to take
the lead in your lifestyle modifications. Your physician can help you
understand the aspects of your lifestyle that may be contributing to
your headaches, but you must make a realistic compromise between
the ideal and the other demands of your life. Significant evidence
indicates that stress, sleep deprivation, hormones, and weather (to
some degree) can trigger headache. Evidence also exists for some,
but not many, food triggers. The best-identified food-related trig-
gers are monosodium glutamate (better known as MSG), alcohol,
and fasting. Sometimes patients develop false but very firmly held
beliefs about the role that food triggers play in their headaches.
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difficulty that the prudence of Turenne was able to keep under the
widespread dissatisfaction.
The policy of Mazarin’s “education” of the young king was already
bearing the fruit of the future misery of the country which his
Eminence’s alien authority so disastrously ruled.
The intimacy of Ninon and Marie Mancini grew into friendship, and
Marie’s confidences made it clear to Ninon that it was her uncle’s
intention, if not her own avowed one, that she should be the wife of
Louis XIV. But the constancy of the great young monarch was ever a
fragile thing.
CHAPTER XII
The Whirligig of Time, and an Old Friend—Going to the Fair—A Terrible

Experience—The Young Abbé—“The Brigands of La Trappe”—The New
Ordering—An Enduring Memory—The King over the Water—Unfulfilled
Aspirations—“Not Good-looking.”
Tempora mutantur. Ninon, in the course of the years which were now
bringing her to middle life, had seen many changes; but when her
friend St Evrémond came back about this time from the wars, after
seven or eight years’ absence, he told her that she had not changed
with them. Beautiful and youthful-looking as ever he assured her she
was, and to prove his words, he took a little mirror in one hand, and
in the other the portrait Rubens had painted of her years before, and
bade her make the comparison herself.
There is little doubt, at all events, that Time’s finger had scarcely
dulled the delicacy of her complexion, or the brightness of her eyes.
Were thanks due to the Man in Black for this? It was a question
she put to St Evrémond very seriously, but the cheery Epicurean had
only a smile and a witticism for answer. The devil, he assured her,
did not exist, and he proposed to escort her to the fair of St Germain
that fine February afternoon. This was scarcely the best way to make
good his assertion; for if his Satanic Majesty was to be found in
Paris, it was certainly in that quarter; for was not the rue d’Enfer,
whence the Capucins had ejected him from his house, hard by?
This, however, had by no means hindered the brethren of St
Germain des Prés countenancing the proceedings, which had come
to be near to an orgy, of the annual market, or fair of St Germain des
Prés—by the letting their ground for it to be held upon. From the
king, to the most villainous of the populace, everybody went to the
fair. The booths were within hail of the ground known as the Pré aux
Clercs, the haunt of the basochiens, the lawyers’ clerks of the Palais
de Justice, away upon the Ile de la Cité, between St Sulpice and St
Germain—the church of the three steeples. The roof of the modern
flower-market now covers this ground. Everything conceivable could
be purchased at the stalls, from the richest silks and velvets to a
pancake or a glass eye, or a wooden leg or a wax arm, or essences
and waters for turning old people young again; every game of
chance, thimblerig, lottery, cards, held out its temptation; every kind
of entertainment, dancing, tumbling, jugglery, music of fiddle and fife,
and drum and tabor—a deafening tintamarre; all kinds of beverages
—wine, cider, tea, coffee—“to drive away melancholy;” syrups were
concocted for the dust-dried throats of the surging crowd of fine
ladies, students, lackeys, soldiers, dainty-shod, short-cloaked, blond-
bewigged abbés, pages, beggars, gipsies. Respectable bourgeois
families rubbed shoulders with flaunting women, and the wretched
crew of mendicant impostors from the old cours de miracles. Often it
was the scene of fracas and fisticuffs and damaged countenances.
On one occasion, a page of the Duc de Bouillon cut off the ears of a
clerk of the basoche and put them in his pocket. The students of the
quarter fell to murderous assault upon the fellow, while the pages
retaliated, and many a dead body of page and student was found
afterwards in the ditches of the Abbaye. At once an earthly paradise
and a pandemonium was the time-honoured annual market of St
Germain des Prés, and in the midst of the madding riot and
confusion a great deal of serious business was transacted among
the merchants and foreign traders who came from afar to exhibit
their wares, as for centuries had been the custom, ever since
mediæval day, when church porches and convent gates were nearly
the only rendezvous for buying and selling.
Not absolutely accepting St Evrémond’s theory, Ninon and her
cavalier left the fair to walk homewards, little thinking that they were
to be confronted by the blood-chilling tale the pale lips of Madame de
Chevreuse poured hurriedly out to them from the window of her
carriage, which she called to a halt as they passed across the Pont
Neuf—a tale upon whose precise details the chronicles of the time
slightly differ, even to casting doubt upon it as a fact, though the
circumstances are no more than consonant with probability. The
beautiful but profligate Madame de Montbazon, it will be
remembered, had been sent by the queen, on account of her glaring
attempts at mischief-making, to reflect upon her misdeeds at Tours.
It was held that she would not find the punishment so tedious and
unpleasant as it might have been if M. l’Abbé de Rancé had not
been in the neighbourhood. He was her lover, and a most ardent
one, constantly by her side, but not to persuade her to penitence; on
the contrary, de Rancé was wild and profligate of life as the woman
he adored. He was brilliantly clever. At school he out-rivalled his
class-fellow Bossuet, and when but thirteen, he published an essay
on the dignity of the soul; and beneath his dissolute ways the gold of
a conscience, of which so many of the Courtly circle in which he
moved seemed absolutely devoid, often shone through. Armand
Jean de Rancé was one of an old and distinguished family, and he
was only ten years old when the Abbey of la Trappe in Normandy
was bestowed on him.
The monastery of la Grand Trappe du Perche, said to have been
so named from its hidden position among the dense forests of the
stormy Norman headland, is of very ancient foundation. It was
established in the twelfth century by Robion, Comte du Perche. The
brethren followed the Cistercian rule, and for several centuries it was
in high repute for the sanctity of its community, and for its wealth,
which was put to its legitimate charitable uses. In course of time, like
so many other abbeys, it was given in commendam, and its pious
repute fell away to such an extent that the seven monks—all that
remained in the monastery—were called by the surrounding
peasantry “the brigands of la Trappe.” They were notorious for their
evil-living, spending the time in drinking and hunting; and shunned
alike by men, women and children, the Trappist monks were the
terror of the district.
It was at this time that the child, Armand de Rancé, was made
Abbé, and affairs at la Trappe continued to fall from bad to worse. As
de Rancé grew up, among many benefices conferred on him, he was
appointed Almoner to the Duke of Orléans, and spent most of his
time in a whirl of dissipation in the Courtly circles in Paris. His
splendid entertainments, his magnificent house, the trappings of his
horses, especially those of the chase, were the talk of Paris, and his
daring intrigues startled even the licence indulged in by the society
he moved in. In this circle de Rancé specially singled out the
stepmother of the Duchesse de Chevreuse, Madame de Montbazon,
a woman as notorious for her profligacy and unscrupulous character
as she was physically beautiful.
After a time spent in banishment at Touraine, she had been
permitted to return to her Paris home, and de Rancé, who had been
absent for a short time, returning to Paris, hastened to call upon her.
Arrived at the house, he found it deserted, and passing in by an
open door, he hurried along the silent passages, calling for the
servants and upon her name, but there was no response. At last he
reached the door of her apartments, and rushing across the
anteroom, he flung aside the portières of her bedchamber. An open,
trestle-supported coffin, across which a sheet lay carelessly flung,
met his eyes, and turning from it to the table close by, the
decapitated head of Madame de Montbazon confronted him.
Momentarily he failed to recognise the features of the ghastly object;
for the face was blurred with the ravages of smallpox. The fell
disease had attacked Madame de Montbazon, and she had died of
it. The body and head were being prepared for embalming, and for
this end—or as some versions of the tale tell, because the coffin had
not been made long enough—the head had been cut off, and placed
upon the table.
The silent horror of this ghastly experience carried an eloquence
beyond all power of words to the heart of de Rancé. Swayed by a
revulsion of feeling, naturally sensitive and imaginative, he looked
back upon his past life with loathing. The hollowness of worldly
pleasures, and uncertainties of a worldly existence were yet still
more deeply impressed upon his mind, by a serious accident he
suffered in the hunting-field, and by the death of his patron, the Duc
d’Orléans. All seemed vanity.
De Rancé was at this time thirty-four years old. With the exception
of the ancient monastery of la Trappe, lost amid the wild forests
verging on the perilous rock-bound shores of extreme North-Western
Normandy, he divested himself of his property and possessions, and
went to take up his residence in la Trappe, endeavouring to establish
the old discipline in it. But the seven spirits he found there were
unruly, and had no mind for being disturbed. So entirely were they
opposed to the abbé’s reforms, that his life was in danger from them,
for they threatened to throw him into the fish-ponds; and Brigadier
Loureur, stationed at Mortagne, the nearest town of importance,
begged de Rancé to accept a guard of his soldiery; but de Rancé
decided that since the brigands of la Trappe had clearly less than no
vocation for the vows of poverty, chastity, and obedience, they were
best entirely got rid of—and he pensioned them off and sent them
away, not in wrath, but in peace. Their place was filled by Cistercian
brethren of the strict observance.
The position of an abbé, or for that matter, an abbess in the ranks
of the Church, had long become an anomalous one. The relaxation
of the old rigid conventual ruling had wrought great changes. It was
not unusual to find some lady of a noble family appointed to the
nominal charge of a monastery, and some equally nobly-born
gentleman set over a community of nuns; and in either case, as
likely as not, they had no knowledge, or next to none, of the
everyday mode of life or working of such community. At the fair of St
Germain the abbés always swarmed thick as flies, in their short
black habits and delicate little linen bands, as where did they not
congregate in the society of the time? The salons of the Hôtel de
Rambouillet and other brilliant assemblies were dotted all over with
them. They were the makers of petits vers and bouts rimés, and, if
nothing more, pretty well indispensable to the following of a fine lady
as cavaliere serventis. They were wont to make themselves
generally amusing and agreeable, everything, in short, but useful to
the spiritual needs of the Church in whose ranks they were
supposed to serve. They wore their vows too lightly for the Abbé de
Rancé to dream of exercising real authority in virtue of the title alone;
and he qualified himself for the dignity he intended to assume of
Superior of the monastery of la Trappe in Normandy—by entering as
a novice in the Cistercian Abbey of Persigny. This ended, he took the
vows, in company with a servant who was deeply attached to him,
and was confirmed abbot.
The order of strict Cistercian observance is rigid in the extreme—
almost utter silence, hard labour, total abstinence from wine, eggs,
fish, and any seasoning of the simple fare of bread and vegetables.
The earnestness and eloquence of de Rancé stirred the men
desirous of joining the brotherhood to such a deep enthusiasm, that
many of them wanted to take the full vows at once; but the Abbé of
la Trappe refused them this, lest they should not have truly counted
the cost of their sacrifice. And not only in this case, but in others the
famous reformer of the ancient monastery showed a singular
judgment and reasonableness in the ordering of his community. And
“his works do follow him”; for still as of old, hidden amid those dark
forests, though not far from the haunts of men, stands the Priory of
Notre Dame de Grâce de la Trappe, its brethren, spending their time
not given to devotion, in alms-giving and healing and acts of charity
of every kind.
In England, meanwhile, great if not unanticipated changes had
befallen. Oliver Cromwell was dead. He had passed away in
comparative peace in his bed. Had his days numbered even a few
more, they might have terminated in assassination, for deep-laid
schemes for this were hatching. The dreary Commonwealth was
growing daily more displeasing, and the English people were longing
for the king to have his own again. It was a day of joy indeed to
Queen Henrietta Maria which saw the progress of King Charles II. to
London. She had some desire that he should wed la Grande
Mademoiselle, Gaston d’Orléans’ daughter; but Mademoiselle
nursed a hope of becoming the wife of her cousin, Louis XIV., a hope
that was not to be realised. Possibly, as Mazarin had said, the
Bastille cannonading had killed that husband; but after her long
wanderings she was again at Court, and in fair favour.
Louis XIV., without being strictly handsome, had agreeable
features and a fine presence, which his pride and self-consciousness
knew very well how to make the most of. He had grown from the
mere youth into a dignified, courtly young manhood, and the want of
knowledge and defective bringing up were fairly well concealed by
“the divinity which doth hedge a king.” It certainly always enfolded
Louis XIV. “Ah, my dear cousin,” cried Queen Christina of Sweden,
when she first saw him, “some one told me you were not good-
looking! Sacré-bleu!” she added, bestowing a sounding kiss on both
of Louis’s cheeks, “if I had the man who told that lie here, I would cut
off his ears before you!” and she still stood gazing admiringly at the
king. So there could be no further doubt about his attractive
appearance; for Queen Christina was accounted an unerring judge
in such matters.
CHAPTER XIII
Christina’s Modes and Robes—Encumbering Favour—A Comedy at the Petit-

Bourbon—The Liberty of the Queen and the Liberty of the Subject—Tears and
Absolutions—The Tragedy in the Galérie des Cerfs—Disillusions.
Christina, ex-Queen of Sweden, was not more nice in style of dress

than she was in the choice of a word to add strength to her
affirmations, and “sacré-bleu” was a mild sponsor for the swear-word
she really selected on the occasion. The startling force of it,
combined with the extraordinary costume she wore, excited an
irrepressible burst of laughter from the queen and from Mazarin, and
all present followed suit—all but the king, who looked disconcerted
and rebukeful.
Christina wore a wig, standing up high over her forehead, with
tufts of curls sticking out, all rough and tousled, on each side of her
face, which was, however, far from really ill-looking. She had on a
coat, which was a cross between a man’s pourpoint and a woman’s
cape, put on so carelessly that it left one shoulder half-exposed. Her
skirt was not cut à la mode into a long train; it was merely a round
petticoat, so short as to afford ample display of leg. A man’s shirt and
a man’s boots completed this costume, in which the great King of
Sweden’s daughter presented herself to the Majesties of France.
She met the risible gaze of the Court with displeasure, and
inquired what they were all staring at. “Am I humpbacked?” she
demanded, “or aren’t my legs well-shaped?” The king, with courtly
good-nature, threw oil on the troubled waters, and Christina was
pacified, observing that Louis spoke like the king and gentleman he
was. “And as for you others,” she added to the rest, “mind
yourselves.”
Ninon, who was indisposed, was not present at this scene; but
recovering some days later, she went to the Louvre, where, thanks to
her friend Madame de Choisy, she came and went constantly; and
as she passed along a gallery leading to that lady’s apartments she
met Madame de Choisy and Christina, who was attired in very much
the same manner as already described, but slightly less outré.
The queen was fascinated at first sight with Ninon. She placed her
two hands on her shoulders and gazed long and fixedly into her face.
“Now I understand, my dear,” she said at last, “all the follies the men
commit, and will commit for you. Embrace me,” and she bestowed
two such sounding kisses on Ninon’s cheeks, as she had bestowed
on the king’s. Then taking her by the arm, she led her to her own
assigned apartments, at the door of which stood two bearded men,
one of them Count Monaldeschi, her Grand Master of the Horse, the
other the successor of the redoubtable Desmousseaux, the
Chevalier Sentinelli, captain of her guard.
Some time before her visit to Paris, Christina had abdicated,
declaring that the formalities and restrictions of the existence of a
crowned queen were unendurable, the cares of a kingdom rendered
life a slavery, and she desired perfect liberty. The liberty she sought
for herself, however, she in no wise extended to others; for while she
renounced her claims to her inherited kingdom, she reserved to
herself absolute and supreme authority, with the right of life and
death over all who should enter her service or be of her suite. Then,
a Protestant born, she joined the Catholic communion. It was
probably a mere caprice; for she did not spare her coarse witticisms
on the newly-adopted faith, and very soon she contrived so seriously
to offend the College of Cardinals that she was forced to leave
Rome, which she had entered on horseback, dressed almost like a
man. After a while she had come to France, and probably somewhat
impressed with the elegancies of the Court, she made some
modification of the hideous attire she had first appeared in. When
Ninon first met her in the Louvre gallery, Her Majesty wore a grey
petticoat skirt of decent length, trimmed with gold and silver lace, a
scarlet camlet coat, her wig was of the unvarying pale yellow hue,
and she carried a handkerchief of costly lace, and a broad-brimmed
hat, plumed with black ostrich feathers. With her white skin, her
aquiline nose and fine teeth, she would have made a very
presentable boy.
She was very voluble, and her immeasurable admiration of Ninon
to her face, was almost disconcerting, even to one so very well
accustomed to compliments. At last, the subject being exhausted,
the ex-queen fell to asking all sorts of questions about the king, the
queen, the cardinal, the new palace at Versailles, the Italian Opera.
Then she had much to say about her own country and her
abdication; about Descartes, who had died at her Court a victim to
the climate; about Count Monaldeschi, with whom, she confided to
Ninon, she was on terms of very close intimacy, and about a
hundred other things.
During Christina’s stay in Paris, Ninon had the delight of seeing
again that most dear friend and protégé of hers, Molière, after his
long absence in the provinces. Christina was with Ninon when he
arrived, and as he and his company were to play that same night the
Cocu Imaginaire, at the Petit-Bourbon, it was arranged that the two
ladies should be present.
Christina had the appetite of an ogress, and before they started for
the theatre, she did ample justice to the handsome repast Perrote
served up. Then Her ex-Majesty summoned her captain of the
Guards, and Grand Master of the Horse—who had been regaled in
another room on turkey and other dainties, and they repaired to the
Petit-Bourbon.
The evening proved anything but enjoyable to Ninon. A market-
woman would have comported herself more decently than this
eccentric, semi-barbarous royal person. She greeted the sallies of
the actors with loud shouts of laughter, and used language that was
rankly blasphemous; while she wriggled and lolled in her chair, and
stretched her feet out among the footstools and cushions, in
appalling fashion. It was in vain Ninon respectfully intimated that the
eyes of everybody were upon them; Christina’s only reply was to beg
her to let her laugh as much as ever she wanted.
The queen’s liking for Ninon grew embarrassing. Six months of her
constant society were almost more than the most good-natured
tolerance could endure, and for that length of time the favour of the
queen’s presence was bestowed on Paris. Then Cardinal Mazarin,
also more than tired of her, entertaining moreover, suspicions that
she was brewing political mischief, contrived to tempt her to seek
change of air and scene at Fontainebleau.
Christina caught the wily cardinal’s bait. Very well—yes, it was a
good idea. She had a great desire to see the renowned palace that
Francis I. had loved so well, and to Fontainebleau, to the relief of
Ninon and of divers other people, the ex-queen went: not to remain
long, however. One morning, at a very early hour, the Chevalier
Sentinelli arrived at the rue des Tournelles and informed Ninon that
she was wanted at the Palais Royal, by his royal mistress, who had
returned to Paris.
It was useless to devise some excuse for not obeying the
summons—invitation, or what it might be—for that was only to bring
the queen herself to the rue des Tournelles; and so to the Palais
Royal Ninon went, to find Christina stretched upon a miserable
pallet-bed, with an evil-smelling, just-extinguished candle on the
table beside her. A serviette did duty for a night-cap, tied round her
head, which was denuded of every hair; for she had had it shaved
close on the previous night. Christina presented a strangely
grotesque and wretchedly miserable picture. Seizing Ninon by both
hands, she told her that she was suffering the deepest agony of
mind—a grief that was horrible—and begged her to stay by her. At
this moment, Sentinelli entered, and a whispered conversation
ensued. “Oh, they will prevent me?” she cried then. “They will
prevent me, will they? Let them dare. Am I not a queen? Have I not a
right to high justice? Very well, then,” she went on, when again
Sentinelli had bent to whisper again. “We must dissimulate. I will go
back to Fontainebleau. There at least, I can do as I please,” and she
prevailed on Ninon to accompany her. And there in the Galérie des
Cerfs at Fontainebleau the hideous tragedy was enacted. The farce
of this woman’s daily life fades out in the thought of her ferocity and
revengeful instincts. Monaldeschi had offended her: he had done
worse, he had been treacherous towards her. Pitiless, with eyes
glittering with rage and hatred, she stood in the Galérie, where the
fading daylight was illumined by the flare of the torches held by her
pages, and taxed the wretched culprit—pleading for mercy at her
feet—with his crimes; but it was not accorded; “Ah, let me live!” he
entreated—“let me live!”
And Ninon, who had dreaded something, but was utterly
unprepared for such a frightful scene, joined her entreaties to his and
to those of his confessor, the monk Lebel. “Ah, no! A woman,” she
sobbed, “cannot give an order for this man to die.”
“I am not a woman,” replied Christina; “I am a queen, and I have
the right to punish a traitor.” She gave the signal. There was a fearful
struggle, the flash of Sentinelli’s sword, an agonised cry, a crimson
stream upon the floor—and then the silence of death.
It had been with extreme reluctance that Ninon had accompanied
the queen to Fontainebleau; but for all Christina’s enigmatical and
elaborate preparations before starting, any conception of her
murderous intentions did not occur to Ninon. She had grown
accustomed to the royal lady’s freaks and eccentricities. On this
occasion, Christina had sent for a confessor, and having attired
herself from head to foot in black, she knelt before him when he
arrived, and first desiring Ninon not to leave the apartment, but to
seat herself in a distant corner of it, she muttered out to the
perplexed-looking Bishop of Amiens—whom she had sent for, he
staying at that time at the Tuileries, spending a kind of brief retreat—
what she had to say.
It occupied some five minutes, and as she proceeded, an
expression of deep discomfiture and perplexity overspread the
bishop’s face. He gave her a hurried absolution, and departed, while
Christina went to the chapel of the Feuillants and communicated. All
these pious preparations had disarmed Ninon of any extreme of
uncomfortable suspicion she might have entertained. Christina could
not possibly be nursing any evil intentions—while Ninon was a
woman, and curiosity had impelled her to Fontainebleau, to see what
was the end of the affair, and find out the cause of such floods of
tears.
In the coach with them were Monaldeschi and Sentinelli. To the
first she did not address a single word throughout the journey. It was
nearing five o’clock, and night was shadowing in, when they arrived;
and when they had had supper, Christina commanded Monaldeschi
to go to the Galérie des Cerfs, where she would presently come to
him. Then she bade Sentinelli follow the count, and motioning Ninon
to accompany her, she proceeded between two rows of Swiss
Guards, armed with halberds tied about with black crape, to the
Galérie. Now thoroughly fearful, Ninon had followed with trembling
limbs. “In Heaven’s name,” she faltered, “what does this mean,
Madame?—something terrible is about to happen.” With an evil
smile Christina threw open the double doors, disclosing
Monaldeschi, with his hands fast bound, kneeling at the feet of
Lebel, whose features were ghastly with consternation at the task
imposed on him, of hearing the doomed man’s confession.
At sight of Christina, Monaldeschi turned, and his agonised cry for
pardon rang through the Galérie; but there was no mercy in that
hideously hate-distorted face; and so, in cold blood, the murder was
perpetrated, and out into the darkness Ninon rushed, calling for a
carriage to bear her from the terrible place, heedless of the queen’s
gibes and endeavours to persuade her at least to remain till morning.
It was nothing—what she had done, she said; “only a traitor had
received his deserts, and the world was well rid of him.”
But the coach drew up, and Ninon fled into its shelter, never
stopping till she reached home. There she took to her bed in a high
state of fever, having ever before her the terrible scene of blood at
Fontainebleau, and for three weeks she remained prostrated by the
memory of it. She never saw Christina again, neither did Paris.
Though the Court took no proceedings against her—insult to
hospitality as her act was, all other considerations apart—she was
avoided, and regarded with loathing, and she planned for herself a
visit to England. But Cromwell had already supped full of murder.
The image of it was sufficiently haunting, and the endeavours of his
conscience to make peace with Heaven before he died were not to
be disturbed by the presence of such a woman. He turned his face
from her instead, and Christina betook herself to Rome, where she
fell deep in debt, and quarrelled fiercely with the pope.
Overweening ambition was the bane of this undoubtedly clever
woman. In the murder at Fontainebleau, it is thought that vanity and
the love of power tempted her to display what she was pleased to
regard as a full length of it. Exactly the nature of Monaldeschi’s
offence remains unexplained. Christina said he had grossly betrayed
her, and some assert that it was politically he had done so; but it
seems more probable that he was a traitor in love. She defended
herself by saying that she had reserved every right of life and death
over all who were in her service. The atrocious deed caused a
sensation in Paris; especially among those of whom the ex-queen
had been a guest, and Anne of Austria sent for Ninon to relate all the
details of her fearful experience at Fontainebleau.
The chief topic of conversation and speculation now was the
marriage of the young king. It was well known that Mazarin hoped to
crown his successful ambitions, by marrying his niece, Marie
Mancini, to Louis, and that Anne of Austria was as strongly opposed
to any such alliance was equally well-known. It was her wish and her
will that Louis should wed the Infanta Maria Théresa. Any thwarting
of this project, the queen vowed, should bring about the setting aside
of Louis, and placing her second son on the throne of France in his
stead—“La reine le veut.” Mazarin had to bite the dust. The
preliminaries for the Spanish marriage were set on foot. The French
and Spanish emissaries met on the Isle of Pheasants. Poor Marie
Mancini, who had a sincere affection for her young royal admirer,
was sent out of the way for a month into the convent of the
Daughters of Calvary, which was hard by Ninon’s house. Louis
whispered in her ear at parting, that if the king was separated from
her, the man would never cease to think of her. Then he whistled to
his dogs, and with his courtly train went hunting in the woods of
Chambord. So ended the love-story of Mazarin’s niece, Marie
Mancini. So much “for the snows of yester year”; but there had been
warm affection between Ninon and the young girl, and they parted
with many tears.
CHAPTER XIV
Les Précieuses Ridicules—Sappho and Le Grand Cyrus—The Poets of the Latin

Quarter—The Satire which Kills—A Lost Child—Periwigs and New Modes—
The Royal Marriage and a Grand Entry.
Molière’s comedy, Le Cocu Imaginaire—which had created such

unrestrainable delight in the ex-queen of Sweden—had been
preceded a year earlier by the famous Précieuses Ridicules. To call
this play the dramatist’s masterpiece, is to do rank injustice to his
work of greater length and importance, notably, if one dare to
choose, to Le Tartufe. The Précieuses, however, took Paris by storm,
and was accounted a gem. Still a delightful little bit of humour, and
not lacking now in its way of a home-thrust, it carried a double-edged
power in the days of the Hôtel de Rambouillet, when the affectations
of speech and conversation had run to such absurd extravagance,
that Molière’s satire was little or no exaggeration. Mademoiselle de
Scudéri’s “Inutile! retranchez le superflu de cet ardente,” is distinctly
precious.
Of the queens of these intellectual réunions, Mademoiselle de
Scudéri was the reigning novelist. Her long life, exceeding Ninon’s in
years, was devoted to the production of romances and the lighter
sort of literature, which ran to a lengthy record. Le Grand Cyrus
stands best remembered, but is scarcely more than a memory. A
long day’s journey would be needed to find the most ardent of fiction-
readers who would now care to follow through the windings of that
romance which in its day created such enthusiasm, and made a
lioness of the amiable if some way from beautiful Madeleine de
Scudéri. Artamène; ou, le Grand Cyrus, after all, was, to be sure,
scarcely fiction. It was composed of little more than thinly-veiled
facts, presenting under classic names the living men and women of
society; heroes and heroines of antiquity stood sponsors to the fine,
broad-skirted, perruqued gentlemen and fashionable dames of
Versailles and the Louvre and the Palais Royal. Artaban, Agathyse,
Zenocrates—these were, in their modish habit as they lived,
severally the Duc de St Bignon, M. de Rainez, M. Ysern, and others
—while Mademoiselle de Scudéri herself was Sappho. It was in her
salon that was drawn up the famous Carte du Tendre—gazetteer of
articles necessary to the pursuit of love. Mademoiselle de Scudéri
wrote with grace and much sense; but her romances were
insufferably prolix. Ninon found them wearisome to a degree, even
though the Grand Cyrus is a record of the great Prince de Condé.
George de Scudéri, Madeleine’s brother, was also a very fertile
novelist of his day, scarcely to be rivalled in speed of production by
Dumas himself. Nor does there appear that the ghosts who worked
for this great, more modern enchanter of the realm of historical
romance, rendered any services to the seventeenth-century novelist.
The salons of Madame de Rambouillet and of Madame de Sablé
were the rendezvous of the most aristocratic of these versifiers and
epigram-makers, who really occasionally uttered something witty or
poetical; though for the most part the wit and poetry did not rise
above such greatness as that of Sir Benjamin Backbite, in Lady
Sneerwell’s drawing-room, on the macaroni ponies whose
“Legs were so slim,
And their tails were so long.”
The refinements and elegance of speech to be heard at those

réunions, fostered, and indeed were a powerful influence in, the
reformation effected by the Académie for the French language. But
the passion for these improvements was often torn to tatters, and the
puerilities and affectations excited a reaction among men of the
more Bohemian class of writers and versifiers, such as Scarron, St
Amand and others, and the curious mixture of real poetic expression
and thought, profanity and coarseness, in their productions, carry
back to the days of Rabelais and of Villon, with echoes of Ronsard
and of Charles of Orléans. But the simplicity and beauty of their
numbers only now and again shone through the grossness of their
compositions, and sheer opposition to the “Clélies” and “Uranies”
and “Sapphos” probably inspired the numerous parodies and the
odes to cheese and good feeding produced by these authors, who
hailed with delight the now famous actor-manager Molière’s
Précieuses Ridicules.
The piece was first produced at the Petit-Bourbon early in the
winter of 1659. The plot, deep-laid if simple, consists of the
successful playing off by two lovers respectively of the two charming
young women they love honestly and deeply, but who meet refusal
on the score of their language being too natural, and their attire not
sufficiently fashionable. The two young men thereupon dress up their
valets, Mascarille and Jodelet, in fine costumes, bestow on them the
titles of marquis and vicomte, and contrive to introduce them to the
précieuses. The exquisite humour of the dialogue between Gorgibus,
the father of one of the two girls, and uncle of the other, sets the ball
rolling; his contempt for the new names, Aminte and Policène, which
they have selected in place of those given them, as he says, by their
godfathers and godmothers; his dim grasp of what he calls their
jargon, when they try to instil into him some idea of its elegancies, is
the essence of genuine comicality, as are the compliments of the two
aristocratic visitors who inform the ladies that it is the reports of their
exquisite attractions and beauty, reaching far and wide, which has
brought them to their feet. Then follows the flutter of delight, veiled
under the attempt at calm graciousness, of the précieuses. “But
Monsieur,” says Cathos to Mascarille, the marquis, inviting him to sit
down, “I entreat you not to be inexorable to this armchair, which has
been stretching out its arms to you for this quarter of an hour past;
allow it the satisfaction of embracing you.” The fun grows apace, as
the slips of tongue and bearing of the two pretended gentlemen
begin to disconcert the two infatuated girls. At last a dance is
proposed, the fiddlers are sent for, and behind them enter the two
masters of the valets, who tear their fine coats off their backs, and
turn them out. “And you,” says Gorgibus, chasing the précieuses
from the room, to repent at leisure of their affectations and thirst for
la galantérie, “out of my sight, and to the devil with all these verses,
romances, sonnets, and the rest of it—pernicious amusements of
do-nothings and idlers!” So the curtain descended on the Précieuses
Ridicules, and the story goes that before very long the play
extinguished the glory of the salon of the Hôtel de Rambouillet.
The Comte de Fiesque, who had gone with Condé to Spain, was
killed in Catalonia by the bursting of a bomb. Ninon, not able
personally to ask the widow where the child was which de Fiesque
regarded as his, commissioned two persons to ascertain for her from
Madame de Fiesque some intelligence concerning its whereabouts,
but the countess asserted that she had no knowledge of this. The
remorse and regret of Ninon were of no avail: she was unable to
trace the lost one.
At last, after long negotiations, Maria Théresa of Austria was
united to Louis XIV. This brought Condé back to allegiance to
France, by the Peace of the Pyrenees, effected by Cardinal Mazarin,
one of the few of his achievements which really benefited France.
Ninon was one in the gorgeous cortège which proceeded to
Grosbois, beyond Charenton, to receive the young princess. It was a
brilliant show. The fashions of the early days of the young king had
greatly changed since his father’s time, which was so greatly
distinguished, at least as far as male attire went, for its elegant
simplicity. Bright hues had superseded the black, the beautiful but
sombre colouring of the material of the silk or satin or velvet doublets
with large, loose slashed sleeves; the falling bands of rich point lace;
the long, straight, fringed or pointed breeches meeting down to the
lace-ruffled or lawn wide-topped boots, and the eminently graceful
Flemish plumed beaver hat. In place of the long hair waving to the
neck, full-bottomed periwigs had come into vogue; the doublets were
short and waistcoatless, displaying a bulging shirt-front, tied with
ribbons to the nether garments, which, like the large loose sleeves,
were covered with points and bows; deep lace ruffles drooped from
the knees, and only the falling collar, with a hat higher crowned than
of yore, but still plumed, remained of the old style.

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Navigating Life With Migraine and Other Headaches William B Young Full Chapter PDF

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Navigating Life with Migraine and Other

Headaches William B Young

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About the AAN’s Neurology Now™ Books Series | xi

Section 1: Managing Your Headaches

2. Pain, Disability, and Stigma in Persons with Headache | 9

3. Classification and Diagnosis of Headache | 13

5. Headaches Requiring Urgent Medical Attention | 31

Section 2: Primary Headache Disorders

The Cause of Migraine | 46

7. Treating Migraine with Medication | 63

8. Alternative and Behavioral Treatments for Migraine | 79

Special Forms of Childhood Migraine | 97

10. Managing the Conditions that Often Coexist with

11. Tension-​Type Headache | 109

12. Cluster Headache | 115

13. Unusual Primary Headaches | 121

Section 3: Secondary Headaches and Neuralgias

16. Post-​Traumatic Headache | 145

17. Trigeminal Neuralgia | 151

18. Atypical Facial Pain and Temporomandibular

Here is a question for you:

diagnosis and respond to your individual needs. Many types of

the physician may result in resolution of the problem. In the second

confident as possible to participate with your doctors in your medi-

Navigating Life with Migraine and Other Headaches is written for

We hope that Navigating Life with Migraine and Other

Managing Your Headaches

Why Headache Is So Important

In this chapter, you’ll learn:

• The scope of migraine as a public health problem

While driving home from work, Kathy was distracted by spar-

FIGU R E 1 .1 A patient’s illustration of the migraine aura.

Still, most people with headache self-​treat or even ignore their

The Headache Experience

Greg thought his head was going to explode. A construction

Headache and Your Family

Headache Has an Impact

Migraine is a public health problem of enormous scope. Twenty-​

What You Can Do

Most of us who experience headache can be safely and effectively

Pain, Disability, and Stigma

In this chapter, you’ll learn:

• That disparity exists between care and funding for headache

Individuals with migraine rate their pain as severe or very severe

generally struggle through most of their attacks, it is common for

Stigma is the perception of a person’s being less worthy than friends

Tiffany has had near-​daily migraine for 10 months. She has

The lack of attention to the disability of headache patients

11. Tension-Type Headache | 109

16. Post-Traumatic Headache | 145

Still, most people with headache self-treat or even ignore their

Migraine is a public health problem of enormous scope. Twenty-

Tiffany has had near-daily migraine for 10 months. She has

TA BL E 3 .1 Migraine or Tension-Type Headache

Characteristics Migraine Tension-type headache

• Tension-type headache pain feels like a tight band or vise