The Purposeful Migraine
The Purposeful Migraine
In the essay "In Bed," Joan Didion writes:
"And once [migraine] comes, now that I am wise in its ways, I no longer fight it. I lie down and let it happen. At first every small apprehension is magnified, every anxiety a pounding terror. Then the pain comes, and I concentrate only on that. Right there is the usefulness of migraine, there in that imposed yoga, the concentration on the pain. For when the pain recedes, ten or twelve hours later, everything goes with it, all the hidden resentments, all the vain anxieties. The migraine has acted as a circuit breaker, and the fuses have emerged intact. There is a pleasant convalescent euphoria. I open the windows and feel the air, eat gratefully, sleep well. I notice the particular nature of a flower in a glass on the stair landing. I count my blessings." (1)
Didion narrates the evolution of her relationship with migraine--from migraine as adversary to migraine as "more friend than lodger" and even "my friend." She suggests that the onset of migraine and her migration through its pain cycles can have a therapeutic end, and that an effort to treat or stop the migraine may, in fact, hinder that end. Didion in no way downplays the severity or pain involved in migraine; indeed, she remarks, "that no one dies of migraine seems, to someone deep in an attack, an ambiguous blessing." But the transformed state of mind that she experiences through migraine, from "in bed" to "euphoria," suggests that migraine itself has helped treat the stress or factors that helped precipitate the event.
Has Didion resigned herself to migraine as an unavoidable and painful process that belies successful treatment? Or does her transformed attitude towards her pain --of migraine as a beneficial event--resonate with other stories of migraine, and even the brain's own migraine process? To view migraine as a progressive function from within the brain and body, rather than as an illness to be attacked from without, does not require a resignation to its pain and symptoms; rather, it should inform attitudes and treatment for migraine, understanding it as a response to deeper conflict within the patient, conflict developing from both internal and external forces.
Migraneurs like Didion have described their affliction for the past 7,000 years, suggesting a universal-both in terms of time and ethnicity--experience of the disorder (2, 3). Within these universal parameters, however, migraine incidence appears higher in European and North American populations than African or Asian populations, and higher among men than women (4). The American Migraine Study found that nearly half of sufferers experience severe headaches for one-to-four days in any three month period; 13% of migraneurs have migraines for ten to nineteen days a month, while 10% of sufferers report migraine for twenty days per month (5).
This widespread migraine incidence impacts society at large both through health care costs and through lost productivity costs. Though a significant portion of the population feels the burden of migraine, both directly and indirectly, many migraneurs do not seek medical treatment. Studies suggest that approximately half of migraine patients have consulted physicians for treatment, a number that has steadily risen in recent years as a result of progress in diagnosis and management and of more acceptance of migraine as a legitimate medical condition (4). Joan Didion alludes to a lack of success in satisfactory medical treatment when she writes: "For I had no brain tumor, no eyestrain, no high blood pressure, nothing wrong with me at all: I simply had migraine headaches, and migraine headaches were, as everyone who did not have the knew, imaginary" (1).
While many feel the direct burden of migraine, few share identical symptoms, causes, or forms. Contemporary researchers regard a migraine as "a specific and unique pathological brain disorder," caused by a variety of triggers on a susceptible brain (6). The International Headache Society outlines the following general criteria for a migraine diagnosis: "Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia" (7). This diagnosis for migraine does not include an aura-a sensory hallucination--and so is often referred to as "Migraine Without Aura," or MO; it is the most common form of migraine, hence the additional name "common migraine."
The criteria for a migraine with aura (MA) diagnosis, often referred to as "classic migraine," differs slightly from MO: "Recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5-20 minutes and last for less than 60 minutes. Headache with the features of migraine without aura usually follows the aura. Less commonly, headache lacks migrainous features or is completely absent" (7). Though less common, migraine with aura has afforded rich soil for investigating the neurological mechanisms of the event.
While a fairly comprehensive definition of migraine exists for the purposes of diagnosis, the cause of migraine remains far more difficult to outline. An ancient Greek theory attributed migraine to "to the ascent of vapors, or humors, from the liver to the head," while 17th century theories suggested the dilation and/or the constriction of blood vessels in the brain (2). In the wake of new technology from brain scans, migraine is now attributed to a disorder of the nervous system, arising from the brain stem and spreading through the cortex in a kind of "brainstorm" or heightened period of nerve cell activity (2). This storm, called "cortical spreading depression," requires a great deal of energy from an increased amount of blood flow. The storm is thought to cause the visual disturbance of the aura, and may introduce the pain that follows, as neurotransmitters are activated to transmit pain signals. Other theories behind the root of migraine pain instead identify the brain stem as the source of the problem, where hyperactivity in the nuclei of the brainstem may relay pain signals and even trigger the spreading depression (2).
What signals such a response in the brain is the next question-and the breadth and variability of migraine "triggers" remains overwhelming. Sacks warns against regarding migraine in a linear, cause-effect system, observing that migraine arises out of a "very complex 'dynamical' system (2). As migraine does have a strong tendency to run in families, a genetic explanation has been sought; but while genetics may contribute to predisposition for migraine, it cannot be attributed to its direct cause, and environmental causes cannot be eliminated (especially since families often share environment as much as genes). Research has confirmed that external stress incites complex processes to take place in the brain, and "nearly every physiological process involved in migraine is affected by stress" (8). When the brain becomes more sensitive to stress or other environmental input, perhaps through a genetic influence, it may then become more susceptible to migraine (9). E. Loder writes in her investigation of the evolutionary advantage of migraine, that "migraneurs are exquisitely responsive to a variety of environmental stimuli" (9).
As migraine is closely linked to the brain's increased sensitivity to stress and other environmental stimuli, so too is it closely linked to psychological response to stress and other environmental conflicts. Furthermore, that chronic pain and recurring migraines might lead to more mental stress, possibly depression, makes sense; in the 19th century, "megrims" or migraines, essentially meant "the blues" (8). Studies of the comorbitidy of mental disorder and migraine have suggested that all may develop from disturbances in the same neurochemical systems, and that such a disturbance may produce one linked disorder rather than separate events (4). Further, there appears to be a "bi-directional" relationship rather than a cause-and-effect relationship between migraine and a mental disorder (6). For example, migraneurs are twice as likely to suffer from depression as those without migraine; and those with depression are twice as likely experience migraine as those with no depression (10). No evidence exists to suggest that migraine causes clinical depression, or depression, migraine; the evidence merely outlines their co-occurrence. Sacks warns against drawing any formal or conclusive connections between emotional needs and migraine occurrence, observing only that "migraine may be summoned to serve an endless variety of emotional ends. As migraines may assume a remarkable diversity of forms, so they may carry as various a load of emotional implications. If they are the commonest of psychosomatic reactions, it is because they are the most versatile" (2).
Studies have revealed a particular relationship between migraine and mental disorder in certain segments of the population. Adolescents who suffer from chronic migraine headaches are at greater risk for suicide than teens without migraine; the adolescents with migraine are also more likely to have other psychiatric disorders such as depression and panic disorder (11). Soldiers returning from Iraq who have migraine headaches are twice as likely as soldiers without migraine to have post-traumatic stress, depression, or anxiety disorders (12). Again, this evidence does not necessarily implicate migraine as a cause of these disorders, nor the disorder as the direct cause of migraine; it merely illustrates that where one issue arises, often the other is present. But while a host of triggers may be at work in sparking the migraine, its strong tie to the emotional disorders does seem to carry, in Sack's phrase, "a load of emotional implications."
In a personal account of his migraine story, Jeff Tweedy, lyricist and lead singer of rock band Wilco, asserts that his migraines were inextricably connected to his mood disorders (13). He believes that the psychological suffering of his childhood mood disorder manifested itself in the form of a migraine-since the pain of the migraine could be more clearly and easily expressed than the pain he felt internally.
Does Tweedy's story suggest, unlike the research cited above, that his mood disorder directly caused the migraine? Again, the host of factors involved in the occurrence of a migraine seems to rule out any direct cause-effect relationship with a particular trigger. But Tweedy clearly links his migraine with his internal pain-finding in the migraine a valuable metaphor for the internal disorder he could not otherwise express. As his mother was a fellow migraneur, he also found from her the sympathy and care which he needed in its treatment. In this example, migraine became for Tweedy a progressive event, as it offered a visible and tangible external expression of his inward pain. Tweedy's experience parallels the psychoanalytic research of migraine. One recent study found that migraineurs showed higher levels of "self-aggression," perhaps similar to the inward pain and self-loathing felt by Tweedy, than did non-migraneur control subjects; and increased levels of self-aggression led to increased headache frequency (8).
Why would the brain respond to stress with a migraine-a response that at first consideration would seem only to incite more stress on the system? Oliver Sacks outlines a stereotypical migraine cycle, describing a patient who, in response to the intensity of her symptoms, drives other thoughts from her mind, may be "stuck, if the attack is very severe, in a leaden, stuporous daze," and retreats from the world into bed and falls asleep (2). When the patient wakes, "the migraine is done, the work is accomplished," and what follows may be a surge of energy, or as Joan Didion described it, "a convalescent euphoria." More generally, Sacks outlines the migraine reaction as "characterized by passivity, stillness and immobilization; commerce with the outer world is minimal, while inner activities-particularly those of secretory and expulsive type-are maximal" (2).
The retreat tendency evident in Sacks's description of the migraine cycle suggests a "defense mechanism" at work in the brain, encouraging the migraneur to escape from his or her harmful environment. As many of the environmental triggers for migraine involve "high levels of sensory, emotional or physical stimuli," it follows that a retreat response in particularly sensitive minds might follow, and an avoidance of such situations would, in turn, develop (9). Migraine, then, works through its pain to progressively signal and rescue the sufferer from a potentially harmful situation--more harmful than the temporary pain of the migraine itself.
Of course, a painful migraine response plagues and inconveniences many patients far more than its seems to rescue them from a life-threatening situation. Nesse and Williams, researchers who investigated the evolutionary advantage of disease, describe a "smoke alarm" theory of the body's defense mechanisms: like a fire alarm, defense mechanisms are finely wired and easily triggered through false alarms, as burning toast might trigger a fire alarm (9). The price of these alarms is unnecessary pain and suffering. Blocking defenses can often be de-activated easily and harmlessly, like removing a battery from a smoke alarm; but such deactivation is helpful only until a real "fire" occurs" (9). Migraneurs may carry a genetic predisposition for particularly sensitive "smoke alarms"-but as these might offer some genuine protection from life-threatening dangers-perhaps the cost of the pain is worth it.
My own migraine story illustrates well this defense story. I experienced my first migraine, with aura, when I was 11 years old. I was enjoying a 4th of July vacation away from home, at my grandmother's house in North Carolina. When I was out playing with my cousins, I started to see strange black dots that morphed into starry structures. I tried to ignore the vision-attributing it to the summer heat, perhaps, or to the physical activity. But after the stars persisted even upon cooling off indoors with a soda, and were then followed by an intense pain in my head, I finally told my mom about my "blurry" vision and bad headache. As we were away from home on a holiday, my best option for medical care was the local emergency room, to which we quickly went. The pain in my head increased tremendously on the trip to the hospital, so that as we arrived at the ER the pain had spread to my stomach in the form of an intense nausea. When I announced that I was about to throw up, I was quickly whisked to a room (ahead of the very full holiday waiting room), vomited, and felt immediate relief (not uncommon for a migraine). I was ready to go home at that point, but the wise ER doctor had already ordered a CT scan of my head.
The scans revealed enlarged ventricles in my brain, which a subsequent MRI and visit to a neurologist back home in Miami attributed to extreme pressure in my brain from aquedcutal stanosis--a diagnosis similar to hydrocephalus in babies, except that I was an otherwise healthy 12-year old. The neurologist recommended immediate surgery for the insertion of a v/p shunt to relieve the pressure, and the following morning a neurosurgeon inserted the shunt and fixed the problem.
The neurologist hypothesized that the headache that sent me to the hospital was a typical classic migraine--and not the direct result of the aqueductal stanosis. Perhaps, though, the migraine was the defense mechanism of my brain--alerting me to the danger of the build up of cerebral spinal fluid. If so, I am glad to have inherited an overly sensitive, migraine-prone brain from my grandmother (who suffered from migraines for much of her adult life) and will endure the false-alarms of many migraines in gratitude for the very real alarm it set off many years ago.
Returning to Dan Tweedy's story of migraine as a result of this mood disorder, perhaps in addition to its value as a physical manifestation of his pain, migraine also offered a valuable and necessary "flight" away from the environmental factors that caused his emotional pain. Perhaps in other mood disorders, too, migraine seeks to function in this defensive role--to draw the migraneur away from the stressors and allow the therapy of sleep and rest to begin. In soldiers this could mean a retreat from the battlefield and its plethora of dangers; in a troubled teen this could mean a retreat from peer pressure, substance abuse, stress, or other harmful stimuli; in a young woman like myself, this could mean a retreat from an abundance of commitments, obligations, deadlines, which, perhaps, threaten to overwhelm the body and mind's natural processes, leaving it more susceptible to illness or other, worse conditions. Pasquale Montagna, in his discussion of the genetic basis of headaches, remarks: "these [retreat] behaviors during the headache attacks really represent "healing" processes, and migraine may be evolutionary advantageous" (14).
Siri Hustvedt, writing in the migraine forum at NYTimes.com, remarks that she has "come to think of migraine as a part of [her], not as some force or plague that infects [her] body" (16). She goes on to observe that this "philosophical resignation" is counter to our culture, in which we constantly "declare war on the things which afflict us." But once she stopped thinking of migraine as "the enemy," she improved--not cured, but better. She now views her migraines as part of her "emotional economy." Her experience has revealed a cycle between "obsessive and highly productive writing and reading," from which she derives great pleasure and satisfaction, and a "neurological crash--a headache." She further observes that her cycles resemble that of bi-polar, except that she falls into migraine rather than extreme depression. Hustvedt absolutely links her migraine with her psychological processes-"our thoughts, attitudes, even our metaphors create physiological changes in us, which in the case of headaches can mean the difference between misery and managing" (15). Hustvedt, also a writer, does not call her migraines a "friend" as did Didion in "In Bed"; but Hustvedt does recognize that her migraines may "serve a necessary regulatory function, by forcing [her] to lie low, a kind of penance, if you will, for those other days of flying high" (15).
Hustvedt views migraine, then, as a counter-balance to times of great thought and productivity. In a similar way, the research of Loder has suggested that migraine may arise from the overwhelming of the old (from an evolutionary stand-point) brain-stem structures by sophisticated cognitive processes taking place in the newly evolved neocortex (9). Loder builds upon recent evidence that identifies in migraine the dysfunction of "pain inhibitory pathways" in brain-stem structures, and speculates that this dysfunction arises from a conflict between the newer and older structures, particularly as the higher brain sends excessive output--perhaps as it processes stressors or other outward conflicts--to the brain-stem (9). Further supporting this theory is the fact that humans appear to be the only species which experiences migraine, suggesting that "superior cognitive abilities and a well-developed awareness of self and environment," functions which reside in the neocortex, may play an important role in migraine (9). Thus, Loder writes, "a vulnerability to recurrent headache may be the price we pay for consciousness. To paraphrase Descartes, 'I think, therefore I have migraine'" (9). Perhaps from Hustvedt's (and my own) migraine point of view it would be better to say, "I have thought too much, therefore I have migraine." In the overly sensitive brain of the migraneur, even an excessive amount of mental energy in the form of thinking, writing, working may manifest itself in a migraine--but on the other side of the migraine, a renewed energy and clean slate for creative work emerges, making the migraine, in the end, a productive, while still painful, process.
Hustvedt also recognizes her migraine as part of her "emotional economy," indicating its purpose in the balance and health of a larger system. Sacks, too, considered the "economics" behind migraine, after seeing a patient, a mathematician, who when he was "cured" of his migraines, was also "cured" of his mathematical abilities; Sacks writes: "he seemed, however paradoxically, to need one for the other" (2). This economy of migraine cured Sacks of his "impatient need" to "treat" the pain in favor of a more deliberate and careful consideration of a migraneur and the "ever-changing features and factors which the migraine patient both suffers and creates" (2).
The complex migraine demands a complex response. As we view migraine in terms of its purpose in the migraineur, both a physical and psychological purpose, progress may be achieved both in its treatment, and more importantly, in the treatment or attention to the stressor that has precipitated the event. Migraine cannot be viewed as an end in itself, nor as an isolated event, but as a purposeful event--that may seek to return the migraineur to the "convalescent euphoria" that Joan Didion came to value. Purpose does not diminish the severe pain, cost, and inconvenience of the headache; but it does affirm the system of which migraine is a part, and the importance of attending to the entire system when considering the cause and treatment of the pain. At the end of Migraine Sacks writes: "...migraine is enthralling; for it shows us...not only an elemental activity of the cerebral cortex, but an entire self-organizing system, a universal behavior, at work. It shows us not only the secrets of neuronal organization, but the creative heart of Nature itself" (2).
1. Didion, Joan. "In Bed." We Tell Ourselves Stories in Order to Live: Collected Nonfiction. New York: Everyman's, 2006. 302-305.
2. Sacks, Oliver. Migraine. Berkeley: UC Press, 1992.
3. Dodick, David W. and Gargus, J. Jay. "Why Migraines Strike." Scientific American. 21 July 2008. <http://www.sciam.com/article.cfm?id=why=migraines-strike&print=true>
4. Olesen, Jen, Tfelt-Hansen, Peer, Goadsby, Peter J., Welch, K. Michael A., and Ramadan, Nabih M. The Headaches. 3rd Edition. Lippincott, Williams & Wilkins, 2005. < http://books.google.com/books?id=VXMI1ry9FgQC&dq=The+Headaches&source=gbs_summary_s&cad=0>
5. National Institute of Neurological Disorders and Stroke. "21st Century Prevention and Treatment of Migraine Headaches." Clinician. December 2001. <http://www.ninds.nih.gov/doctors/OP129A_Clinician_fa.pdf>
6. National Institute of Neurological Disorders and Stroke. "21st Century Prevention and Management of Migraine Headaches." The Clinical Courier. September 2001. <http://www.ninds.nih.gov/doctors/OP129D_Clinical_Courier_fa.pdf>. (Slightly version than source 5.)
7. International Headache Society. "The International Classification of Headache Disorders." Cephalalgia: An International Journal of Headache. Vol. 24, Supplement 1, 2001. <http://126.96.36.199/ihscommon/guidelines/pdfs/ihc_II_main_no_print.pdf> (via Bryn Mawr journal database)
8. Borkum, Jonathan. Chronic Headaches: Biology, Psychology, and Behavioral Treatment. Routledge, 2007. < http://books.google.com/books?id=0WIIi_MyqiYC&printsec=frontcover&dq=Chronic+Headaches#PPA351,M1>
9. Loder, Elizabeth. "What is the evolutionary advantage of migraine?" Cephalalgia: International Journal of Headache (2002) 22:624-632.
10. Tepper, Stewart J. Understanding Migraine and Other Disorders. Jackson: Univ. of Miss. Press, 2004.
11. American Academy of Neurology. "Teens with Migraine at Greater Risk of Suicide." Science Daily. 1 May 2007. <http://www.sciencedaily.com/releases/2007/04/070430181213.htm>
12. American Academy of Neurology. "For Iraq Veterans, Migraines may be Sign of Other Problems." Science Daily. 4 May 2007. <http://www.sciencedaily.com/releases/2007/05/070503075228.htm>
13. Tweedy, Jeff. "Shaking it Off." Migraine: Perspectives on a Headache. NYTimes.com. 5 March 2008. <http://migraine.blogs.nytimes.com/2008/03/05/shaking-it-off/>
14. Montagna, Pasquale. "The primary headaches: genetics, epigenetics and a behavioural genetic model." Journal of Headache Pain. (2008) 9:57-69. <http://www.springerlink.com.proxy.brynmawr.edu/content/388m81878hr18124/fulltext.pdf> (via Bryn Mawr database access)
15. Hustvedt, Siri. "Arms at Rest." Migraine: Perspectives on a Headache. NYTimes.com. 7 Feburary 2008. <http://migraine.blogs.nytimes.com/2008/02/07/arms-at-rest/>