There screen’d in shades from day’s detested glare,
Spleen sighs for ever on her pensive bed,
Pain at her side, and megrim at her head.

Dr. Sacks’s primary purpose in writing this book was, no doubt, to enlighten his fellow practitioners about a complaint of which most of them know all too little. As Dr. Gooddy says in his Foreword:

The common attitude is that migraine is merely a form of mainly non-disabling headache which occupies far more of a busy doctor’s time than its importance warrants…. Some tablets and the current inelegant cliché of “learning to live with it” are advised by the physician, who hopes he will not be on duty the next time the patient comes for advice…. Many doctors are only too pleased when a patient, in desperation, takes himself off to the practitioners of “fringe medicine,” almost hoping that the results will be both disastrous and very costly.

I am sure, however, that any layman who is at all interested in the relation between body and mind, even if he does not understand all of it, will find the book as fascinating as I have.

It has been estimated that migraine afflicts at least 10 percent of the human race and the true percentage may well be higher, since probably only those who suffer severe attacks consult a doctor. Even if, like myself, one has had the good fortune never to have experienced an attack, we all have known some relative or friend who has had them, so that we can compare their character traits and symptoms with Dr. Sacks’s detailed descriptions.

Unlike contagious diseases and genetic disabilities such as hemophilia on the one hand, and hysterias on the other, migraine is a classic example of a psychosomatic illness in which physiological and psychological factors play an equal role. As physical organisms we are pretty much the same, that is to say, our bodies have a limited repertoire of symptoms. This makes it possible to diagnose a case of migraine, to distinguish it from, say, epilepsy or asthma. But as conscious persons who can say I, each of us is unique. This means that no two cases of migraine are identical; treatment that succeeds with one patient can fail with another.

A migraine is a physical event which may also be from the start, or later become, an emotional or symbolic event. A migraine expresses both physiological and emotional needs: it is the prototype of a psychophysiological reaction. Thus the convergence of thinking which its understanding demands must be based simultaneously, both on neurology and on psychiatry…. Finally, migraine cannot be conceived as an exclusively human reaction, but must be considered as a form of biological reaction specifically tailored to human needs and human nervous systems.

The first part of Dr. Sacks’s book consists of a series of detailed clinical observations. He distinguishes between three types of migraine, common migraine, popularly called “a sick headache,” classical migraine, in which, as in epileptic attacks, there is frequently a distortion of the visual field, and migrainous neuralgia, or “cluster headache,” so called because attacks are closely grouped. These descriptions, interesting as I found them, I do not feel qualified to discuss.

I will mention two curious observations Dr. Sacks makes. He tells us that the “Nightmare Song” in Iolanthe mentions no fewer than twelve migraine symptoms, and that the visions of the medieval nun, Hildegard of Bingen, were clearly visual auras caused by classical migraine.

Part Two is devoted to the questions: “What circumstances trigger off a migraine attack?” and “Is there a migraine personality?” The evidence is bewilderingly diverse. Thus, migraine often runs in families, but Dr. Sacks believes this is probably learned from the family environment, not genetically inherited, for many patients have no such family history.

Though classical migraine more commonly attacks young people and males, this is not invariable, and the first attack of common migraine may occur after the age of forty, among women, for example, during their menopause. Classical migraine and cluster headache tend to occur for no discernible reason at regular intervals, varying from two to twelve weeks; common migraine seems more dependent upon external and emotional situations. Some cases resemble allergies: an attack can be caused by bright lights, loud noises, bad smells, inclement weather, alcohol, amphetamines. Others suggest a hormonal origin: migraine is not uncommon among women during their menstrual periods, but very rare during pregnancy.

Such a diversity naturally produces an equal diversity of theories as to the basic cause of migraine. The somatically orientated physician looks for a chemical or neurological solution, the psychiatrist for an exclusively psychological answer. Dr. Sacks thinks that both are only half-right. Of the psychological theories the two most accepted are those of Wolff (1963) and Fromm-Reichmann (1937).


Migraineurs are portrayed by Wolff as ambitious, successful, perfectionistic, rigid, orderly, cautious, and emotionally constipated, driven therefore, from time to time, to outbursts and breakdowns which must assume an indirect somatic form. Fromm-Reichmann is also able to arrive at a clear-cut conclusion: migraine, she states, is a physical expression of unconscious hostility against consciously beloved parents.

Dr. Sacks’s experiences with his patients have led him to conclude that while many are, as Wolff says, hyperactive and obsessional, there are others who are lethargic and sloppy, and that while, as Fromm-Reichmann says, most migraine attacks are a somatic expression of violent emotions, usually rage, this may be a reaction to an intolerable life situation of which the patient is quite aware, and may also be self-punitive.

We find, in practice, that sudden rage is the commonest precipitant, although fright (panic) may be equally potent in younger patients. Sudden elation (as at a moment of triumph or unexpected good fortune) may have the same effect…. Nor should one claim that all patients with habitual migraine are “neurotic” (except in so far as neurosis is the universal human condition), for in many cases the migraines may replace a neurotic structure, constituting an alternative to neurotic desperation and assuagement.

In Part Three, Dr. Sacks discusses the physiological, biological, and psychological factors in migraine. His theories about its biological basis I found particularly interesting and suggestive. Among all animals are to be found two possible reactions to a situation of threat or danger, fight-or-flight and immobilization. He quotes Darwin’s description of the second:

The picture of passive fear, as Darwin portrays it, is one of passivity and prostration, allied with splachnic and glandular activity (“…a strong tendency to yawn…death-like pallor…beads of sweat stand out on the skin. All the muscles of the body are relaxed. The intestines are affected. The sphincter muscles cease to act, and no longer retain the contents of the body….”). The general attitude is one of cringing, cowering, and sinking. If the passive reaction is more acute, there may be abrupt loss of postural tone or of consciousness.

He believes that, despite the association between migraine and rage, it is from this passive reaction, tailored to human nature, that migraine is biologically derived. This seems to me very plausible. Before he invented weapons, primitive man must have been one of the most defenseless of all the creatures, being devoid of fangs or claws or tusks or hooves or venom, and a relatively slow mover. It seems unlikely, therefore, that aggression or rage can have been a basic biological instinct in man as it is in the predator carnivores. Human aggression must be a secondary modification of what was originally a feeling of terror and helplessness. As Coleridge said: “In all perplexity there is a portion of fear, which disposes the mind to anger.”

Dr. Sacks concludes his chapter on psychological approaches to migraine by saying that three kinds of psychosomatic linkage may occur.

…first, an inherent physiological connection between certain symptoms and effects; second, a fixed symbolic equivalence between certain physical symptoms and states of mind, analogous to the use of facial expressions; third, an arbitrary, idiosyncratic symbolism uniting physical symptoms and phantasies, analogous to the construction of hysterical symptoms.

The last part is devoted to the problems of therapy. As in all cases of functional disorders, the personal relation between doctor and patient is of prime importance. “Every sickness is a musical problem,” said Novalis, “and every cure a musical solution.” This means, as Dr. Sacks says, that, whatever method of treatment a physician may choose or be forced to choose, there is only one cardinal rule:

…one must always listen to the patient. For if migraine patients have a common and legitimate complaint besides their migraines, it is that they have not been listened to by physicians. Looked at, investigated, drugged, charged: but not listened to.

Dr. Sacks recognizes that there are drugs, notably Ergotomine Tartrate and Methysergide, which can relieve the pain of an acute attack, and which it would be heartless to refuse a patient, unless he has other physiological conditions which counterindicate their use, but he regards them as somewhat dangerous palliatives which cannot effect a permanent cure.

His own bias, he tells us, is toward psychotherapy, but he is modest in his claims. He does not think, for example, that the only solution to migraine is depth analysis, for which few patients have either the money or the time. Further, he admits that some patients find a psychotherapeutic approach unacceptable.

Severely affected patients should be seen on a regular basis, at intervals—approximately of two to ten weeks. The early interviews must be long and searching, in order to expose for both patient and physician the general situation and specific stresses which are involved, while establishing the foundations of the physician’s authority and the patient-physician relationship; later consultations may be briefer and more limited in scope, and will chiefly be concerned with the discussion of current problems as these are experienced by the patient and expressed in his migraines. Cursory medical attention is disastrous, and an important cause of allegedly “intractable” migraine.

He also recommends the keeping of two calendars, a migraine calendar and a calendar of daily events, which may reveal unsuspected circumstances as provocative of attacks.


“Cure,” in his opinion, means finding for each particular patient the best modus vivendi for him. This can mean, in certain cases, allowing the patient to “keep” his headaches.

The attempt to dislodge severe habitual migraines in a pathologically unconcerned or hysterical personality may force the patient to face intense anxieties and emotional conflicts which are even less tolerable than the migraines. The physical symptoms, paradoxically, may be more merciful than the conflicts they simultaneously conceal and express.

Such patients would agree with Marx: “The only antidote to mental suffering is physical pain.”

This Issue

June 3, 1971