Migraine

Summary

Migraine is a recurring disorder of the nervous system whose central features have remained recognizable for two thousand years (Sacks, Oliver, 1970/1992). A typical attack moves through a sequence of stages — prodrome, sometimes a sensory aura, a headache phase, and a long resolution — and may involve nausea, mood change, light and sound intolerance, drowsiness, and fluid disturbances (Sacks, Oliver, 1970/1992) (Sacks, Oliver, 1970/1992). It crosses the boundaries of neurology, psychiatry, and internal medicine because it is a physical event that is also, often, an emotional and biological one (Sacks, Oliver, 1970/1992). The canonical modern monograph is Oliver Sacks’s Migraine (1970, revised 1992), which treats the condition as both a clinical entity and a test case in the philosophy of medicine — a disorder that resists single-cause explanations and demands a triple description as process, reaction, and experience (Sacks, Oliver, 1970/1992).

The Clinical Picture

Sacks identifies several syndromes within what he calls the “migraine-complex”: common migraine (the everyday headache form), migraine equivalents (in which headache is absent and other symptoms dominate), the migraine aura (which when followed by headache becomes classical migraine), and migrainous neuralgia (cluster headache) (Sacks, Oliver, 1970/1992). Headache is never the only symptom, and it is not a necessary feature of every attack — a point Sacks insists on at the outset, since the word “migraine” can otherwise mislead (Sacks, Oliver, 1970/1992).

The cardinal symptoms of common migraine are headache and nausea, joined by a “general feeling of disorder” (du Bois Reymond’s phrase) that may be expressed in physical or emotional terms and often eludes the patient’s powers of description (Sacks, Oliver, 1970/1992). The headache is unilateral in onset more often than not but tends to become diffuse later; at least a third of patients experience bilateral pain (holocrania) from the start (Sacks, Oliver, 1970/1992). Throbbing occurs in less than half of cases, synchronized with arterial pulsation when present, but its absence does not exclude a vascular headache (Sacks, Oliver, 1970/1992). Nausea is invariable, and Sacks reads the term in both literal and figurative senses — a turning-away from food, from everything, and a turning-inward (Sacks, Oliver, 1970/1992).

Mood change is itself a primary symptom, not merely a reaction to pain: anxious irritability early in the attack, then apathy and depression, sometimes a mixture of despair, fury, and loathing in the severest cases (Sacks, Oliver, 1970/1992). Photophobia, phonophobia, and a more general sensory irritability arise from a diffuse central excitation, and the blandest foods may acquire intensely disgusting flavors (Sacks, Oliver, 1970/1992). A peculiar migrainous drowsiness — uncomfortable, oppressive, sometimes verging on coma — is to be distinguished from the natural sleep that may end an attack (Sacks, Oliver, 1970/1992). Du Bois Reymond’s old distinction between “red migraine” (face flushed, plethoric) and “white migraine” (face pale, drawn, ashen) still has descriptive value; the white form is far more common (Sacks, Oliver, 1970/1992).

A prodromal stage may precede the attack proper by hours or days, with hunger, restless hyperactivity, insomnia, vigilance, and emotional arousal that may be either anxious or euphoric in colouring. George Eliot, herself a sufferer from severe common migraines, would speak of feeling “dangerously well” the day before her attacks (Sacks, Oliver, 1970/1992).

The attack ends in one of three classical ways, recognized since the seventeenth century: by lysis (gradual fading with secretory activity), by sleep (deep and refreshing, like post-epileptic sleep), or by crisis (a sudden eruption of physical, visceral, or emotional activity that ends the attack within minutes) (Sacks, Oliver, 1970/1992). Resolution by lysis resembles a catharsis on both physiological and psychological levels — the hateful migraine mood melting away with the physiological secretion, “like weeping for grief” (Sacks, Oliver, 1970/1992). The common factor in resolution by crisis is arousal: the patient is awoken from the migraine as if from sleep, and most drug therapies likewise serve to arouse the organism from physiological depression (Sacks, Oliver, 1970/1992). To grasp migraine clinically, the entire sequence (prodrome, attack proper, resolution, rebound) must be denoted by the term — limiting the meaning to the headache stage makes the disorder unintelligible (Sacks, Oliver, 1970/1992).

Migraine Equivalents

A migraine is an aggregate of innumerable components, and “migraine equivalent” denotes symptom-complexes that share the generic features of migraine but lack a specific headache, by analogy with epileptic equivalents (Sacks, Oliver, 1970/1992). Edward Liveing was the first to trace what he called the “transformations” and “metamorphoses” of migraine — asthmatic, epileptic, vertiginous, gastralgic, pectoralgic, laryngismal, and maniacal forms in which one paroxysm replaces another (Sacks, Oliver, 1970/1992). Cyclic vomiting and bilious attacks are common in juvenile cases and may persist or pass into adult common migraine (Sacks, Oliver, 1970/1992). Abdominal migraine — epigastric pain of continuous severity with chilliness, slow pulse, and nausea — was incisively described by Liveing and may convert in adulthood to the classical form (Sacks, Oliver, 1970/1992). Premenstrual syndromes show the same arousal-then-let-down structure on the menstrual cycle (Sacks, Oliver, 1970/1992). Heberden in 1802 noted hemicrania ceasing on the coming of asthma; Sacks observed at least twenty patients in whom asthma, angina, or laryngospasm replaced migraine attacks (Sacks, Oliver, 1970/1992), and warned that purely symptomatic treatment of one symptom may simply drive the patient through an endless repertoire of “allied reactions” (Sacks, Oliver, 1970/1992).

Gowers, in his 1907 Borderland of Epilepsy, framed faints, vagal attacks, vertigo, sleep symptoms, and migraine as protracted minor epileptic events whose nature could not be suspected because of their length (Sacks, Oliver, 1970/1992). Sacks then distinguishes “migranoid attacks” (recurrent and familial, near migraine but not of it) from “migranoid reactions” (akin to migraine but provoked rather than spontaneous: motion sickness, hangovers, drug responses) (Sacks, Oliver, 1970/1992). Some patients show a “polymorphous syndrome” in which migraine, asthma, peptic ulcer, ulcerative colitis, psoriasis, urticaria, and angina coalesce or alternate — one such family, Sacks remarked, “seemed to be committing physiological suicide” (Sacks, Oliver, 1970/1992). The conclusion is structural: “Compact and clearly defined at its center, migraine diffuses outwards until it merges with an immense surrounding field of allied phenomena. The only boundaries which exist are those which we are forced to adopt for nosological clarity and clinical action” (Sacks, Oliver, 1970/1992).

Migrainous Neuralgia, Hemiplegic, and Pseudo-Migraine

Migrainous neuralgia (cluster headache, Horton’s cephalalgia, histamine headache) has been redescribed and renamed a dozen times since Möllendorff’s 1867 account; the pain may be of overwhelming intensity — one of Sacks’s patients described it as “an orgasm of pain” — and patients pace in fury rather than lying down (Sacks, Oliver, 1970/1992). Cluster headache is almost ten times commoner in men than women, rarely familial (only 3 of Sacks’s 74 cases had a family history), and shows close-packed groupings of attacks for several weeks (up to ten daily) followed by months or years of remission, with annual clusters often around Easter (Sacks, Oliver, 1970/1992) (Sacks, Oliver, 1970/1992). True hemiplegic migraine — motor hemiplegia of hours’ or days’ duration following a classical attack — is exceedingly rare, often strongly familial, and Symonds’s 1951 case showed transient cerebrospinal-fluid pleocytosis and EEG slowing on one hemisphere (Sacks, Oliver, 1970/1992). Organic lesions — angiomas, aneurysms, temporal arteritis, stroke — may mimic migraine, and suspicious features include invariable unilaterality of aura, late-life onset, or auras that lack the normal Jacksonian march (Sacks, Oliver, 1970/1992). Permanent neurological damage from migraine is, however, very rare; of more than 1,200 migraine patients Sacks examined, none experienced lasting damage. “For all its miseries, migraine is an essentially benign and reversible condition” (Sacks, Oliver, 1970/1992).

The Aura

The migraine aura is the most strange and the most studied part of the syndrome. Sacks frames it as “a veritable Africa of prodigies” inside us, a region that is “touched with the incomprehensible and the incommunicable” (Sacks, Oliver, 1970/1992). The word “aura” itself comes from Pelops, Galen’s master, who interpreted the rising sensation that begins many attacks as a “cold vapour” or “spirituous vapour” passing up the vessels (Sacks, Oliver, 1970/1992).

The classical visual aura begins as a sudden brilliant luminosity near the fixation point in one half-field; from there a scotoma expands into a giant crescent or horseshoe whose advancing margin shows the gross zigzag pattern that justifies the term fortification spectrum and finer brilliant angles (“chevaux de frise”) best shown in Karl Lashley’s 1941 self-observed sketches. The scintillation rate falls between 8 and 12 per second, and the margin takes 10 to 20 minutes to cross the visual field (Sacks, Oliver, 1970/1992). Migraine paraesthesiae differ from epileptic Jacksonian march in two ways: they travel some hundred times more slowly, and they become bilateral in more than half of cases (especially lips and tongue), unlike epileptic auras that begin unilaterally (Sacks, Oliver, 1970/1992). Chorea — a “twinkling movement or motor scintillation” — that arises from the basal ganglia and brainstem during some attacks supports Sacks’s view that migraine is at root an arousal disorder, located in the deep brain rather than the cortical mantle (Sacks, Oliver, 1970/1992).

The aura may also include affective and cognitive disturbances: sudden eruptions of dread or angor animi (mortal fear), with the qualities William James ascribed to mystical states (ineffability, noetic quality, transiency, passivity) (Sacks, Oliver, 1970/1992); “mosaic” and “cinematographic” vision, in which the visual image fractures into polygonal facets or appears as a flickering series of stills, demonstrating what happens when the brain-mind’s construction of space and time is unmade (Sacks, Oliver, 1970/1992); and the Hughlings-Jackson “dreamy state,” in which a quasi-parasitical state of consciousness coexists with normal awareness — a “mental diplopia” (Sacks, Oliver, 1970/1992). Freud, himself a sufferer from classical migraines, observed that slips of the tongue and forgetting of proper names often warn of an imminent attack, and in March 1895 sent a summary of his ideas on migraine to Fliess (though he never published on the subject) (Sacks, Oliver, 1970/1992).

The aura is composite at every moment: variable components arranged in countless patterns, with both excitatory and inhibitory phases on a contracted timescale of 20-30 minutes. Its symptoms are central and cerebral, in contrast to the largely peripheral and vegetative symptoms of common migraine (Sacks, Oliver, 1970/1992). Walter Alvarez found that 87 per cent of 44 surveyed physicians had experienced “many solitary scotomata with never a headache,” suggesting the true incidence of the aura is far higher than the cited 1 per cent prevalence of classical migraine (Sacks, Oliver, 1970/1992). Hughlings Jackson resolved the migraine-epilepsy classification problem by separating theory from practice: scientifically migraine belongs with the epilepsies, but it would be as absurd to class it with ordinary epilepsy in clinical practice “as to class whales with other mammals” (Sacks, Oliver, 1970/1992). Classical migraine is thus an aggregate structure composed of aggregate structures: aura and headache stages have a contingent link but no necessary connection, and may be dissociated by ergot derivatives or spontaneously (Sacks, Oliver, 1970/1992). The current terminology has replaced “classical” and “common” with “migraine with and without aura”; the prevailing opinion is that there is no essential epidemiological, clinical, or physiological difference between them (Sacks, Oliver, 1970/1992).

The 1992 postscript to chapter three brings the aura into contact with Gerald Edelman’s theory of “primary consciousness.” A deep scotoma — in which space, time, and the personal world all vanish — is a scotoma in primary consciousness and the body-ego, providing a brief but overwhelming impression of “the absolute identity of Body and Mind,” and showing that consciousness and self are not entities above the body but neuropsychological constructs dependent on bodily integration (Sacks, Oliver, 1970/1992). Pascal’s recurring l’Abime — the precipice yawning to his left that he warded off with furniture — was probably a migrainous left hemianopia, exemplifying the metaphysical angst that part of space itself has vanished (Sacks, Oliver, 1970/1992).

Hildegard’s Visions

Hildegard of Bingen (1098-1180) experienced “visions” from earliest childhood that, in Sacks’s reading, “leave no room for doubt” as to their migrainous nature; her Scivias illustrations show shimmering star-points, concentric wave forms, and clear fortification figures radiating from a coloured central point (Sacks, Oliver, 1970/1992). Sacks reads her vision of “The Fall of the Angels” — “a great star most splendid and beautiful, and with it an exceeding multitude of falling stars … And suddenly they were all annihilated, being turned into black coals” — literally, as a phosphene shower in transit across the visual field followed by a negative scotoma (Sacks, Oliver, 1970/1992). Her case provides “a unique example of the manner in which a physiological event, banal, hateful, or meaningless to the vast majority of people, can become, in a privileged consciousness, the substrate of a supreme ecstatic inspiration,” comparable to Dostoevsky’s epileptic auras (Sacks, Oliver, 1970/1992). Charles Singer first proposed the migraine reading in 1917; Sacks elaborated it; Sabina Flanagan and others have contested it as a reductive naturalistic reading of a complex mystical life (Newman, 2020) (Newman, 2020).

The History

The clinical picture of migraine — its periodicity, relation to character and circumstance, and physical and emotional symptoms — had all been clearly recognized by the second century of the common era, when Aretaeus of Cappadocia described it under the name Heterocrania: “the whole head is pained, and the pain is sometimes on the right, and sometimes on the left side … there is much torpor, heaviness of the head, anxiety; and life becomes a burden. For they flee the light; the darkness soothes their disease” (Sacks, Oliver, 1970/1992). Two categories of theory have dominated medical thinking on migraine since Hippocrates: the humoral theory and the sympathetic theory; both, variously transformed, command wide assent today, and Sacks suggests current chemical theories are intellectual descendants of the ancient humoral doctrines (Sacks, Oliver, 1970/1992) (Sacks, Oliver, 1970/1992).

Thomas Willis’s 1672 treatise De Anima Brutorum contained a section (“De Cephalalgia”) that Sacks calls the first modern treatise on migraine and the first decisive advance since Aretaeus, organizing medieval observations on migraine, epilepsy, and other paroxysmal reactions (Sacks, Oliver, 1970/1992). Willis revived the classical concept of idiopathy — a tendency to periodic and sudden explosions in the nervous system — applying it to migraine and epilepsy alike (Sacks, Oliver, 1970/1992). The eighteenth-century clinicians (Tissot, Whytt, Cheyne, Cullen, Sydenham) made no arbitrary distinctions between physical and emotional symptoms; this unity was fractured at the start of the nineteenth century when “nervous disorders” were rigidly divided into “organic” versus “functional” and partitioned between neurologists and alienists (Sacks, Oliver, 1970/1992). Sacks’s central thesis is that this partition has impoverished the clinical understanding of migraine, and that the disorder must be reclaimed as a psychophysiological one in which “physical and emotional symptoms occur at every stage in constant concomitance and cannot be described in terms of one another” (Sacks, Oliver, 1970/1992).

Edward Liveing’s 1873 treatise On Megrim, Sick-Headache, and Some Allied Disorders is, Sacks holds, the Victorian masterpiece on the subject. Liveing ordered the entire range of migrainous experience and proposed the theory of “nerve-storms”: the fundamental cause is “a primary and often hereditary disposition of the nervous system itself; this consists in a tendency to the irregular accumulation and discharge of nerve force” (Sacks, Oliver, 1970/1992) (Sacks, Oliver, 1970/1992). Sacks treats Liveing’s text as a methodological touchstone and follows it in his own historical exposition, noting that “many of the major theories which exist today were in circulation in Liveing’s time, and his comments on them retain their relevance today” (Sacks, Oliver, 1970/1992).

The mid-twentieth century brought Harold Wolff’s vascular theory, which dominated migraine medicine from the 1930s to the 1960s. Wolff’s experimental work showed that the intensity of migraine headache is closely proportional to the dilatation of extracranial arteries, with vasodilatation producing a sterile inflammation through accumulation of pain-threshold-lowering “headache stuff” in the scalp (Sacks, Oliver, 1970/1992). Sacks accepts this account of the headache phase but argues that the parallel Latham-Wolff vasoconstrictor hypothesis cannot explain the aura: cortical vessels have never been observed during an aura, aura and headache stages can overlap, polysymptomatic auras show simultaneous excitation and inhibition, and the special features of scotomata cannot arise from simple ischaemia (Sacks, Oliver, 1970/1992). He likewise dismisses chemical theories (histamine, acetylcholine, serotonin) as descendants of the humoral theory: even James Lance’s serotonin findings represent concomitance not causation, and migraines persist despite methysergide treatment that depresses systemic serotonin (Sacks, Oliver, 1970/1992). Reductive single-mechanism accounts, Sacks holds with Borges, “lack interest, for they cannot cast light on the full complexity of the migraine problem” (Sacks, Oliver, 1970/1992). Sacks’s own electrophysiological work added a small but striking finding: monitoring the EEG in identical twin sisters during severe scotomatous auras revealed enormous slow-waves in the delta range (1-3 Hz) confined to occipital electrodes, which disappeared in minutes as vision returned — the first electrical correlate of the aura (Sacks, Oliver, 1970/1992).

Theoretical Frameworks

Sacks’s central methodological move is to refuse single-cause explanation. The opening of Part III of Migraine states the position plainly: “to explain migraine we need three sets of terms, three universes of discourse.” Migraine must be described simultaneously as process (a neurophysiological event), as reaction (a reflexological or behavioural pattern), and as experience (a psychological or existential intrusion into the world of meaning). “It is impossible to make any adequate statement on the nature of migraine without considering it, simultaneously, as process, as reaction, and as experience” (Sacks, Oliver, 1970/1992).

Throughout the book, this commitment plays out as what Sacks calls “a continuous double-vision” — envisaging migraine as a structure inherent to the nervous system and as a strategy that may be employed to emotional or biological ends (Sacks, Oliver, 1970/1992). To follow it requires “a sort of mental diplopia and a double language” — Hughlings Jackson’s term (Sacks, Oliver, 1970/1992). All migraines are composite at every moment: common migraine, equivalents, and aura share a structure of variable components surrounding a stable core of arousal disorders — alterations of conscious level, muscular tone, and sensory vigilance (Sacks, Oliver, 1970/1992). The disorder is variable in three ways only: in length (condensed or extended in time), in vertical level of nervous-system involvement (cortical to autonomic), and in collateral combinations of symptoms (Sacks, Oliver, 1970/1992). Sacks proposes a five-stage prototype — initial excitation, engorgement, prostration, recovery (crisis or lysis), rebound — with affect and somatic symptoms synchronized at each stage (Sacks, Oliver, 1970/1992).

In structural terms, the migraine sequence is one of excitation followed by inhibition or “derousal.” This places it on a continuum with epilepsy, sleep, and even psychotic cycles. Where Gowers placed migraines, faints, and sleep-disorders in the borderland of epilepsy, Sacks notes that we may equally locate migraine in the borderland of sleep (Sacks, Oliver, 1970/1992). Migraine is no more a suspension of all activities than sleep or psychotic stupor: it is “a paradoxical combination of inner violence and outer detachment” — analogous to dreaming in paradoxical sleep, with inhibition at one level releasing excitations at others (Sacks, Oliver, 1970/1992).

The Biological-Reaction Theory

Sacks then anchors migraine in evolutionary biology. He frames it as a Konorskian protective reflex — a withdrawal of the whole body “from the operation of a noxious or endangering stimulus” — and distinguishes it from the active fight-flight reactions described by Walter Cannon and Hans Selye (Sacks, Oliver, 1970/1992). Darwin’s distinction between active fear (terror) and passive fear (dread) anchors the biological account: dread is characterized by passivity, prostration, increased splanchnic and glandular activity — the protective reaction of which migraine is the human exemplar (Sacks, Oliver, 1970/1992). Throughout the animal world a repertoire of passive responses to threat exists: hedgehog curling, jerbil cataplexy, opossum sham-death, the chameleon’s freezing and colour-change. “The ultimate paradox is the simulation of death to avoid death” (Sacks, Oliver, 1970/1992). Sacks postulates an “Urmigraine” — a crude passive-protective-parasympathetic reaction of long duration, ancestor to migraine, refined by the unique possibilities of human nervous systems and the cultural repressions that demand vegetative retreat where direct action is not possible (Sacks, Oliver, 1970/1992). The complex aura, by contrast, Sacks describes as a by-product of the unique differentiation of the human cortex — only the hierarchically ordered neuronal fields of the human brain permit such complex sensory and integrative disturbances (Sacks, Oliver, 1970/1992).

The physiological organisation of migraine, Sacks argues, follows Walter Rudolf Hess’s terms “ergotropic” (sympathetic activity with central arousal, organism turned outward) and “trophotropic” (parasympathetic with inward orientation): the major part of a migraine “represents a polymorphic trophotropic syndrome” (Sacks, Oliver, 1970/1992). A common migraine is then a three-stage paroxysm in slow motion — prodromal ergotropic predominance, trophotropic collapse, ergotropic rebound — and Sacks proposes (echoing Liveing) that it may be conceived as a centrencephalic seizure projected rostrally on the cortex and peripherally through the autonomic nervous system (Sacks, Oliver, 1970/1992). He then borrows Hughlings Jackson’s hierarchical model of the nervous system to explain migraine variability: the same migraine sequence can be expressed at the highest Jacksonian level (a complex aura), the middle (an elementary aura), or the lowest (a common migraine or equivalent) (Sacks, Oliver, 1970/1992). Alexander Luria’s post-Pavlovian functional-systems theory provides another resource: a function is a shifting constellation directed toward a biological task, the task remaining constant while intermediate mechanisms may be freely interchanged. “There may be as many ways of concocting a migraine as of cooking an omelette” (Sacks, Oliver, 1970/1992). The conclusion of Part IV is therefore that “it may be chimerical to search for a unique and pathognomonic migraine process in the nervous system” — there will be no spike-and-wave equivalent, since migraine grades into a continuous borderland of allied paroxysmal reactions (Sacks, Oliver, 1970/1992).

Periodic and Circumstantial Migraines

Periodic migraine occurs at fairly regular intervals irrespective of mode of life — peculiarly characteristic of classical and cluster forms — while common migraine and equivalents tend to depend on external or emotional circumstances (Sacks, Oliver, 1970/1992). There is “a tendency towards a reciprocal relation between the frequency and the severity” of periodic attacks: as one of Liveing’s patients put it, “I have a certain quantity of suffering which I must go through, however it is broken up or divided” (Sacks, Oliver, 1970/1992). After a severe periodic attack there is a period of absolute immunity to further attack, which diminishes by degrees until the next attack is “due” (Sacks, Oliver, 1970/1992). These forms exemplify Willis’s idiopathy and Liveing’s “nerve-storms,” which Sacks calls “an incomparable metaphor” (Sacks, Oliver, 1970/1992). The 1992 postscript invokes James Clerk Maxwell’s “singular points”: in nonlinear dynamical systems, infinitesimal events can precipitate enormous results once a critical configuration is reached, and the relation between stimulus and response ceases to be linear (Sacks, Oliver, 1970/1992).

Sacks distinguishes “arousal migraines” (provoked by activating circumstances — light, noise, smells, exercise, violent emotion, pain, drugs) from “slump migraines” (provoked by exhaustion, sedation, eating, fasting, heat, sleep) (Sacks, Oliver, 1970/1992). Violent emotions exceed all other acute precipitants in their capacity to provoke an attack; sudden rage is the commonest, paradoxically arresting the organism in mid-excitement. Only “kinetic” emotions in James Joyce’s sense ignite migraines — never the “static” emotions of dread or awe, which are expressed in stillness (Sacks, Oliver, 1970/1992). “Resonance migraine” can be elicited immediately by flickering light at 8-12 Hz — the same band that triggers photo-myoclonus and photo-epilepsy — producing a scintillating scotoma that matches the stimulus rate (Sacks, Oliver, 1970/1992). Allergic mechanisms are rare: less than one per cent of migraine attacks are explicable in allergic terms (Sacks, Oliver, 1970/1992). Migraine can become self-perpetuating, a positive-feedback response to itself in which stimulus and response fuse (Sacks, Oliver, 1970/1992); and circumstantial migraines have a protective function, warning against excessive arousal or exhaustion alike (Sacks, Oliver, 1970/1992). Migraine is also amenable to conditioning: any expectation may evoke an attack, by the same logic that produces an allergic response from a paper rose. “Virtually any theory of migraine may come to generate the data on which it is based,” Sacks notes, citing Gibbon: “the prediction, as is usual, contributed to its own accomplishment” (Sacks, Oliver, 1970/1992).

Migraine and the Person

Migraine headache occurs in roughly 5 to 20 per cent of the general population, with about a tenth experiencing readily-recognized cephalgic migraines. Classical migraine is rarer (~1 per cent), migrainous neuralgia rarer still, and the hemiplegic and ophthalmoplegic forms exceedingly rare (Sacks, Oliver, 1970/1992).

The mid-twentieth century produced two stereotypes that Sacks rejects. Wolff’s “migraine personality” — ambitious, perfectionistic, rigid, emotionally constipated — and Frieda Fromm-Reichmann’s theory that migraine is the somatic expression of repressed hostility against beloved persons both fail at the bedside. Sacks’s habitual migraine sufferers were too various to fit either stereotype “unless I played Procrustes” (Sacks, Oliver, 1970/1992). Migraines may be summoned to serve an endless variety of emotional ends; their versatility, not a stereotyped emotional substrate, is what makes them the commonest of psychosomatic reactions (Sacks, Oliver, 1970/1992). Sacks identifies six strategic uses of habitual migraine — recuperative, regressive, encapsulative, dissociative, aggressive (with an emulative subtype), and self-punitive — patterns that may interact and combine, making many attacks “as richly over-determined as dreams” (Sacks, Oliver, 1970/1992). Three forms of psychosomatic linkage may obtain: an inherent physiological connection between symptoms and affects, a fixed symbolic equivalence between symptoms and states of mind (analogous to facial expression), and an arbitrary idiosyncratic symbolism uniting symptoms and phantasies (as in hysterical symptom-formation) (Sacks, Oliver, 1970/1992).

The clinical literature of the early twentieth century is also riddled with what Sacks calls a “romantic” view of migrainous constitution (Tourraine, Alvarez, Greppi): small trim quick-witted women with red hair, acromegaloid skulls, and outstanding intelligence — a flattering picture sharply at odds with the menacing accounts of the epileptic constitution and its supposed “hereditary taint.” Sacks suggests this may have something to do with the fact that most writers on migraine themselves suffer from migraine (Sacks, Oliver, 1970/1992). He decisively rejects the unitary “migraine personality” idea on the same grounds: clinical heterogeneity proves that migraine patients are “an exceedingly heterogeneous group” — some hyperactive, some lethargic, some obsessional, some sloppy, some brilliant, some simpletons — and the heterogeneity invalidates statistical claims built on the fiction of an “average migraineur” (Sacks, Oliver, 1970/1992).

The same critique applies to genetic explanations. Sacks rejects Goodell, Lewontin and Wolff’s 1954 inference of a recessive gene with 70% penetrance as “highly suspect and even absurd,” for the simple reason that familial incidence does not necessarily imply inheritance: a family is also an environmental circumstance of enormous potency (Sacks, Oliver, 1970/1992). Friedman’s finding that 65 per cent of migraine patients and 40 per cent of patients with tension-headaches give a family history of their respective symptoms makes the point — no one suggests tension headaches are genetic, yet they propagate through family “style” (Sacks, Oliver, 1970/1992). Sacks closes the chapter on predisposition with Freud’s epistemological dictum: hereditary explanations are admissible “only when one strictly observes the correct order of precedence, and, after forcing one’s way through the strata of what has been acquired by the individual, comes at last upon traces of what has been inherited” (Sacks, Oliver, 1970/1992). The migraine population merges into the general population at every point; everyone, every organism, has the potential for reactions akin to migraine, but this potential is exalted in a fraction of the population (Sacks, Oliver, 1970/1992). Migraine itself may lie dormant for half a century and erupt under environmental provocation: Sacks’s Case 15 concerns a 75-year-old woman whose childhood classical migraines returned with fortifications and paraesthesiae after her husband’s death, then disappeared again with grief resolution (Sacks, Oliver, 1970/1992).

The case material in chapter 9 makes the same case against single-cause psychological reductionism. Case 81 describes a Holocaust survivor who had monthly classical migraines from age seven until his incarceration in Auschwitz, where he experienced not a single attack despite losing his entire family; the migraines returned after liberation along with chronic depression, accompanied by accident-proneness and psychotic episodes that could substitute for migraines. Sacks reports several similar accounts, suggesting that “all forms of psychosomatic illness, and also frank psychosis, were apparently extremely rare in such conditions, presumably because they would have been lethally mal-adaptive” (Sacks, Oliver, 1970/1992). Case 56 presents a woman whose well-known pregnancy remission of migraine occurred only in three planned pregnancies, never in the fourth unwanted one — illustrating that pregnancy remission is at least as much a psychological as a hormonal phenomenon (Sacks, Oliver, 1970/1992). Case 83 is the only patient in Sacks’s series who fit the classical “migraine personality”: a hyper-driven engineer with a “hypertrophied drive” working seven-day weeks, whose Sunday migraines “acted as physiological Sabbaths” (Sacks, Oliver, 1970/1992). Sacks closes by invoking Borges: such illnesses represent “apparent desperations and secret assuagements” — they may replace a neurotic structure rather than express one (Sacks, Oliver, 1970/1992).

Sacks resolves the nature/nurture dilemma by treating migraine as both innate and acquired — innate in its fixed generic attributes, acquired in its variable specific ones. The analogy he draws is to Chomsky’s universal “deep grammar,” which is innate while every particular language is learned: “Walking, at its most elementary, is a spinal reflex, but is elaborated at higher and higher levels until, finally, we can recognise a man by the way he walks, by his walk. Migraine, similarly, gathers identity from stage to stage, for it starts as a reflex, but can become a creation” (Sacks, Oliver, 1970/1992). Migraine constitutes “a primitive bodily language” — a set of inner gestures and autonomic postures analogous to involuntary facial expressions, “an ancient and universal mode of expression — a primordial language of the body — implicit in the structure and functioning of the nervous system” (Sacks, Oliver, 1970/1992). He distinguishes Franz Alexander’s two psychosomatic mechanisms — “vegetative neuroses” (Darwin’s direct nervous action: physiological accompaniments of emotional states) and “conversion symptoms” (substitute symbolic expressions of repressed emotion) — and concludes that migraine uses both: it is “an outstanding example of such a mixed device” (Sacks, Oliver, 1970/1992). Part III closes with Wittgenstein: “What can be shown cannot be said. The human body is the best picture of the human soul” (Sacks, Oliver, 1970/1992).

The 1992 Postscripts: Chaos and Self-Organisation

Where the original 1970 edition built its synthesis on Liveing, Hughlings Jackson, Hess, Luria, and Pavlov, the 1992 revision adds a layer drawn from chaos theory and dynamical-systems biology. Sacks proposes that migraine should be understood as a complex dynamical disorder of neural regulation — a far-from-equilibrium “metastable” state that may itself act as a “strange attractor” pulling the nervous system into chaos (Sacks, Oliver, 1970/1992). “The exquisite control (and, normally, latitude) of what we call health may, paradoxically, be based on chaos,” he notes, especially in the autonomic nervous system (Sacks, Oliver, 1970/1992).

Part V — co-authored with Ralph Siegel — develops this further through the geometry of the aura. Sacks distinguishes three levels of geometrical hallucinosis in migraine: phosphenes (seeing stars), the classical scintillating scotoma with fortifications, and rapidly-changing detailed geometrical patterns of lattices, mosaics, and spirals (Sacks, Oliver, 1970/1992). Heinrich Klüver’s “form constants” from his mescaline studies — lattice/honeycomb, tunnel/cone, spiral, cobweb — appear identically in migraine, sensory deprivation, hypnagogic hallucinations, fever delirium, cerebral ischaemia, and epilepsy. The constants must reflect a fundamental cortical organisation, not the etiology of the attack (Sacks, Oliver, 1970/1992). Karl Lashley’s 1941 self-observations of his own scotomata, in which he plotted the rate of enlargement against the known dimensions of the striate cortex, calculated a wave of cortical excitation moving at about 3 mm per minute — confirmed decades later by Leão’s spreading depression in animals and by 1990s magnetoencephalography in humans, where Welch directly visualized the wave during an aura (Sacks, Oliver, 1970/1992). Sacks and Siegel propose a self-organisation account drawn from Ilya Prigogine’s “order through fluctuations”: such patterns reflect spontaneous order from a far-from-equilibrium nonlinear dynamical system (Sacks, Oliver, 1970/1992). Their 400-neuron supercomputer simulation produces three migraine-like behaviors depending on a single parameter — the strength of synaptic connectivity — and the third regime spontaneously generates the geometric lattices, radial forms, and spirals of the mature third-stage hallucinosis (Sacks, Oliver, 1970/1992). “We have a natural laboratory, a microcosm, in our own heads,” Sacks concludes — migraine reveals not only the secrets of neuronal organisation but the workings of a wider class of self-organising systems in nature (Sacks, Oliver, 1970/1992).

Therapeutics

Sacks’s general therapeutic philosophy, set out in chapter 14, is relationship-centered. The doctor-patient relationship is central in the management of all functional disease — “his authority, his sympathy, and the countless intangible and largely unconscious bonds … are as important as the sense or otherwise of anything he says and does” (Sacks, Oliver, 1970/1992). The cardinal rule is to listen: “if migraine patients have a common and legitimate second complaint beside their migraines, it is that they have not been listened to by physicians. Looked at, investigated, drugged, charged: but not listened to” (Sacks, Oliver, 1970/1992). He warns that severe habitual migraine may serve as a defense, and that physical symptoms “may be more merciful than the conflicts they simultaneously conceal and express.” Removing migraines may unmask intolerable anxieties — illness can play the same paradoxical role as severe neurotic symptoms, “the double role of city walls” (Sacks, Oliver, 1970/1992).

On drug therapy, Sacks rejects the wonder-drug idea: “There have never been any such wonder-drugs, and never will be” (Sacks, Oliver, 1970/1992). Ergotamine tartrate is the best available drug for severe migraine headache (helpful in roughly 80 per cent of attacks), but must be administered at the very start of an attack; it must never be given in pregnancy and is contraindicated in Raynaud’s, Buerger’s, and severe coronary disease (Sacks, Oliver, 1970/1992). Methysergide is the most powerful prophylactic but benefits no more than a third of severe sufferers; serious side-effects include vasoconstrictive ischaemia, retroperitoneal fibrosis (which can be clinically silent and progress to hydronephrosis), and bizarre cerebral effects related to the drug’s close chemical kinship with LSD (Sacks, Oliver, 1970/1992). He condemns surgical procedures — hysterectomy, oophorectomy, tonsillectomy, and tooth extraction have all been performed for migraine; if remission follows, surgery played “the role of a particularly monstrous placebo or satisfying some intense masochistic need,” and he compares this to Victorian castration for epilepsy (Sacks, Oliver, 1970/1992). By 1992 he had become more skeptical of aborting attacks: one of his patients chose “to be violently ill for three hours, and then perfectly well” over “vaguely ill and wretched for two to three days,” and Sacks observes that “the very intensity and incessancy of ‘treatment,’ these days, may serve to aggravate, not alleviate, the malady it seeks to help” (Sacks, Oliver, 1970/1992).

The Hippocratic note runs through this whole chapter. The best migraine clinic Sacks ever saw “was one where the sufferer was led, without an unnecessary movement or words, to a darkened cubicle, where he could lie down and rest, and receive a pot of tea and a couple of aspirin”; the results, even with severe classical attacks, were “far more impressive than anything I had seen in other clinics.” This was Hippocrates’s central message: “one must not treat the disease, but the afflicted individual,” allowing the vis medicatrix naturae — the healing power of nature — to act (Sacks, Oliver, 1970/1992).

The historical chronicle of migraine remedies in Appendix III makes the same point in reverse. Willis (1672) records his patient — “a most noble Lady” — was “deaf to the charms of every Medicine” after futile trials of mercury salivation, blood-letting, artery opening, mineral spas, travel to Ireland and France, and “all famous Specificks” (Sacks, Oliver, 1970/1992). Heberden (1801) cataloged the eighteenth century’s failed remedies — bloodletting, Peruvian bark, valerian, fetid gums, myrrh, musk, camphor, opium, hemlock, sneezing powders, blisters, electrification — and noted bleeding “has been very detrimental” (Sacks, Oliver, 1970/1992). Gowers (1892) advocated nitroglycerine continuously between attacks, combined with tinctures of nux vomica, gelsemium, and Indian Hemp; he also wrote the indispensable line that “the measures that do good in one case will fail in another, apparently quite similar” (Sacks, Oliver, 1970/1992).

The 1992 Sumatriptan Chapter

Chapter 16 — added in 1992 — narrates the transformation of migraine medicine across the previous two decades. Sacks dates the shift to 1960 and the introduction of methysergide; before then, migraine was thought predominantly psychosomatic, but, as Neil Raskin recalls, “Suddenly, patients could take a few tablets of methysergide and within a week they were headache-free. No change in their internal milieu. Cured” (Sacks, Oliver, 1970/1992). Magnetoencephalography in the early 1990s gave the first direct evidence that Aristides Leão’s “spreading depression” occurs in human visual cortex during a migraine aura — a magnetic wave with excited spikes at its rim and depressed slow waves in its wake, moving at 2-3 mm per minute, just as Lashley had calculated decades earlier (Sacks, Oliver, 1970/1992). Migraine has been induced experimentally in non-migraine patients by deep-brain electrodes stimulating raphe nuclei in the brainstem, providing the first clear demonstration that migraine originates in brainstem neuron firing rather than in the cortex (Sacks, Oliver, 1970/1992). Lance’s unifying hypothesis envisages attacks initiating in the hypothalamus, descending to the periaqueductal grey and raphe nuclei, where they affect cortical microcirculation (initiating spreading depression and the aura) while reducing pain perception by closing a spinal pain-gate; the subsequent monoamine collapse then opens the gate and floods the head with previously-inhibited pain (Sacks, Oliver, 1970/1992). The discovery of this brainstem “final common pathway” made a specific drug at last conceivable, and sumatriptan — synthesized in the late 1980s — is the first selective 5-HT1 agent. Sacks confesses that he had to revise his earlier “plastic functional system” framing of the disorder: “we can scarcely speak of a migraine having a tactic; a migraine has a mechanism, but a mechanism which can be understood, and, in principle, greatly modified” (Sacks, Oliver, 1970/1992).

But this revision is not a capitulation to wonder-drug thinking. Sacks describes biofeedback as making “some normally-invisible something … strongly visible and present to consciousness, so that the will could apprehend, and hopefully change it” — patients learn to diminish temporal artery pulsation or raise hand skin temperature, sometimes with dramatic effect (Sacks, Oliver, 1970/1992). And his clinical perspective on 1992 patients introduces the idea of a “migraine identity”: with frequent attacks, patients may need a convalescent period to learn how to be well after the affliction retreats. The Sunday-migraine patient (Case 18) recovered only after working through “the putative need for illness in his life” (Sacks, Oliver, 1970/1992).

Significance for Philosophy of Medicine

Migraine matters as a test case in the philosophy of medicine because it resists the dominant explanatory style of biomedicine. It is the disease that defeats single-cause / single-cure thinking. Sacks frames the book as not merely a description but a meditation on the unity of mind and body and on migraine as an exemplar of psychophysical transparency (Sacks, Oliver, 1970/1992). A migraine is “a physical event which may also be from the start, or later become, an emotional or symbolic event” — the prototype of a psychophysiological reaction whose understanding requires the convergence of neurology and psychiatry, and whose form is specifically tailored to human nervous systems (Sacks, Oliver, 1970/1992). William Gooddy’s foreword captures the methodological gift the disorder offers: in no other condition can we see “the complete physiological experiment in a human being … the gradual disintegration of function of the normal person, exactly as we do in a case of stroke or of brain tumour; but without the disaster of the permanent disability” (Sacks, Oliver, 1970/1992). Every patient with classical migraine, Sacks remarks, “opened out, as it were, into an entire encyclopaedia of neurology” (Sacks, Oliver, 1970/1992).

The clinical method that follows from this is the listen-to-the-patient method, set against the wonder-drug method. The most severely afflicted of Sacks’s early patients defeated his therapeutic endeavours until he began to enquire into their emotional lives, at which point it became apparent to him that many migraine attacks were “drenched in emotional significance” (Sacks, Oliver, 1970/1992). The disorder asks of medicine what medicine has been most reluctant to give: a sustained attention to the singular case in its full physiological-emotional-symbolic density, and a willingness to inhabit the “double language” of the psychophysiological domain.

See Also

• oliver-sacks
• edward-liveing
• thomas-willis
• aretaeus-of-cappadocia
• william-gowers
• john-hughlings-jackson
• hildegard-of-bingen
• psychophysiological-disorder
• paroxysmal-disorder
• epilepsy
• vis-medicatrix-naturae
• clinical-narrative-medicine

Sources

• Sacks, O. (1992). Migraine: Revised and Expanded (2nd ed.). University of California Press. [sacks-migraine-1992]
• Newman, B. (2020). Hildegard of Bingen: A Visionary Life. (Cited only for the historiographical note on the migraine reading of Hildegard’s visions.) [newman-hildegard-of-bingen-2020]

Editorial Notes

Gaps the encyclopaedia compiler flagged for future evidence work.

• Newman 2020 citations (new20-vita-004, new20-ch03-001) already woven into the Hildegard section above. Further reception-history depth would require dedicated Singer and Flanagan monograph evidence.