Intro & Writing Style

First of all, if you suffer from migraines (or perhaps are affected in a secondary manner), you should buy this book without a second thought. If you don’t have migraines, but are interested in neurology, hallucinations, and/or strange and bizarre clinical cases, this should also be a great read.

A few words about Oliver’s writing. For the most part it's very understandable; he breaks down and builds up concepts in a clear and concise manner. The book is well organized. There are five main sections, each of which contains a few chapters, each of which is broken up into smaller chapter sections. This organization makes it really easy to find a specific topic, as well as to fit individual ideas into the bigger picture. That being said, certain sections where he shotguns a storm of medical lingo are a bit more challenging to understand. There were pages where I had to stop five or six times to check a definition on Merriam Webster. Beware: you may need to brush up on your high school bio. Some words you'll run into every few pages are:

• autonomic
• sympathetic
• parasympathetic
• pathognomonic
• vasoconstriction

Most of these (except for pathognomonic) should look pretty familiar. They looked familiar to me, but I forgot what they meant. The trickiest words are those with multiple meanings. I read around 100 pages thinking that vegetative was being used in a “couch potato” kind of way. Turns out it can also mean autonomic. Woops. Suffice it to say, if you’re not studying for med school, you might need a dictionary.

Alright, got the boring parts out of the way. I’m gonna talk about the content now, which hopefully is not that boring. We’ll start with section 3, and then work our way out concentrically to the first and last sections. That was a joke. We’ll start with section 1.

The Experience of Migraine

This section is, as you may have guessed, about the experience of migraine. It covers a variety of migraine types and their symptoms. In other words, this section answers the question "what is a migraine" from the subjective perspective of a migraineur (i.e. a connoisseur for migraines).

We recognise a migraine as being constituted by certain symptoms of a certain duration in a certain sequence. (111-113)

This definition is somewhat vague, which is appropriate for the subject at hand. Sacks says that the structure of a migraine can vary in three ways: length, levels (i.e. which levels of the nervous system it affects), and symptoms. In other words, there are a million different things which can be called a migraine. Say you have an intense unilateral headache every time you smell blue cheese. That's a migraine. Say you have a bilateral headache and nauseau at 2pm on the third Thursday of every month. Migraine. Say you have no headache, no nauseau, but instead intense abdominal pain whenever you see a puppy. Also a migraine (or, if you prefer, migraine equivalent). I've gotten a little ahead of myself by mentioning how these migraines occur; this section merely covers the symptoms. I hope these examples give at least a general idea of how varied a migraine can be. If not, then this list of possible systems might help:

• headache
• nauseau
• itching or burning in the eyes
• sensitivity to light
• blurred vision
• stuffy nose
• stomach pain
• bowel problems
• drowsiness
• fever

And that's just a few. We've now covered the first major idea of this section: migraine is an umbrella term, and drastically varies from person to person.

By now, I imagine you desperately desire to know the second major idea, and the third major idea, and the fourth major idea, and so on and so on. Unfortunately, there is only one other major idea. It's pretty simple too, and here's how it goes: migraines, based on their symptoms, can be classified into three categories: common migraine, migraine equivalent, and classic migraine.

The common migraine is characterized by headache and nausea. But wait, there's more. There are a number of symptoms which may accompany the leading duo, some of which are listed above. Basically, a common migraine is what springs to mind when someone says "I have a migraine."

Migraine equivalents are migraines, but without the headache. That is, they have the same form and structure as migraines, but different symptoms. One pleasant example is periodic diarrhoea (did you know how this was spelled? it looks weird). If you get diarrhoe from the same circumstances, or with the same periodicity as one might get migraines, it's classified as a "migraine equivalent."

Classic migraines are migraines with auras; an aura is a sensory hallucination. The name "classic" might be misleading. It implies that these types of migraines are uncommon and out of date, which is a total lie. It might also hint at something old and boring. For example, a friend might come up to you and say "yo have you read Pride and Prejudice by Jane Austen, it's a classic!". I'd imagine you'd respond with something like "nah, that book is super old and boring read something more modern like Harry Potter and the Prisoner of Azkaban." It turns out migraine auras are fascinating, almost as fascinating as the adventures of the boy who lived.

The chapter on classical migraines is the longest in the book, and for good reason. This stuff is crazy. The length of the post is already getting a little out of hand, so I'm going to keep it very short (hopefully). If it sounds interesting, buy the book and read this one chapter (chapter 3). It'll be worth it.

Alright. We know that a classic migraine is a migraine with an aura. But what happens when you get just the aura, with no headaches or other migraine symptoms occuring before or after? That's still a migraine. See how general this term is? It's kinda like if we called bagels and lox the same thing. There are many different types of bagels, and sometimes they come with lox. But you can also eat the lox by itself. Therefore the lox is a bagel. That was a terrible analogy and is probably logically inconsistent but whatever. Here are some interesting examples of migraine auras:

• zoom vision: vision zooms in and out
• mosaic vision: stuff starts to look pointilliste, then mosaic, then cubist (or some subset/combination of those)
• cinematographic vision: stuff starts to look like a movie playing at 12fps
• scintillating scotoma: sparkling and jagged lines appear across the vision
• negative scotoma: certain parts of the visual field disappear
• bagel vision: a specific type of negative scotoma where people's heads look like bagels (i.e. a ring of flesh surrounding a void)

One more thing. Migraine auras are somewhat special in that the recipient is completely conscious/aware during the aura. Thus, a lot of migraineurs have created cool visualizations of their auras. You can check some of them out here.

The Occurence of Migraine

Wow, that previous section is way too long. I just wanted to write a quick and dirty review of this book, and now I'm summarizing the whole thing like I'm doing a third grade (fifth grade?) book report. I'll try to use less words for these other sections.

This section is about when migraines occur. Remember how in the previous section, we classified migraines based on their symptoms? Now we're gonna classify them based on their occurence. This gives us the following three categories:

• periodic and paroxysmal migraine
• circumstantial migraine
• situational migraine

Periodic and paroxysmal migraines are characterized by a recurring schedule. Ideally, this category would only contain migraines that occur irrespective of the mode of life. In other words, nothing in particular causes the migraines; they just happen. For example, a woman who gets menstrual migraines every month, no matter what she does, would have a periodic migraine. Note: it may seem like there's some cause and effect going on here. To clarify, we can think of periodic migraines as being an innate aspect of an individual. Then, just as women have periods "built-in," people can have migraines "built-in." However, periodic migraines have a gray area. A migraine may appear to be periodic, but really be caused by a recurring situation. For example, if a professor works intensely hard Monday through Friday and gets a migraine on Saturday, she would have a circumstantial migraine. Psychological aspects might also come into play. Specifically, occurence of migraines could be encouraged by expectancy. In other words, if a person expects to get a migraine according to a certain schedule, and that expectation is somehow met a few times, that schedule might become reality. Think Lavar Ball and speaking things into existence.

Circumstantial migraines are migraines that arise under certain conditions. For example, light, noise, odours, weather, exercises, pain, and fasting can all cause migraines. More specifically, "looking at bright lights" could be the circumstances in which one gets a migraine.

Situational migraines are migraines that arise under certain situations. This sounds extremely similar to circumstantial migraines; the main difference is that situations are internal, and cirumstances external. While circumstantial migraines depend largely on one's environment, situational migraines depend more on the individual's mental state. For example (case 81 in the book), consider a 55-year-old man. He's an Auschwitz survivor. However, his entire family died there; he's the only one who escaped. Since then, he's been "chronically depressed, guilt-ridden, [and] preoccupied with the deaths of all his relatives" (168), and gets 10 migraines every month. These migraines are an emotional outlet, a way to express his guilt in a self-harming manner. Note how emotions, and not surroundings, are the cause of these situational migraines.

Thus we might wonder, from the start, whether such circumstantial migraines are best considered as reactions to overwhelming emotion, and situational migraines as expressions of chronic, repressed, emotional drives. (217)

The Basis of Migraine

Ok, I'm actually gonna make this shorter. This section talks about what causes a migraine. There are three (yet another trio!) types of causes:

• Physiological
• Biological
• Psychological

The physiological causes are not completely understood. The following sums it up fairly nicely.

The migraine reaction is characterised, at lower functional levels, by protracted parasympathetic or trophotropic tonus, preceded and succeeded by physiological opposite states. At its higher functional levels, it is characterised by activation (and succeeding inhibition) of countless cortical fields, from the primary sensory areas to the most complex integrative areas. Migraine is considered as a form of centrencephalic paroxysm in slow-motion, in the case of the aura 20 to 200 times slower, and in the case of a common migraine some thousands of times slower, than their epileptic counterparts. It is also necessary to consider migraine as a complex adaptive task performed by a complex functional system, in which the means of performance (which are extremely variable) are subordinated to its ends. (203)

Basically, migraines span many physiological levels, and are kind of like a slower version of epilepsy.

Animals have two types of protective reflexes. The first is fight-or-flight. The second is what I'm gonna call hide-and-cry. As examples, consider the chameleon, the opossum, and the skunk. These animals use camouflage, fake death, and smelly stuff to "avert" danger. Migraine can be seen as a complex extension of a primitive hide-and-cry reaction. As humans have grown in complexity so have migraines, which has led to a complex and varied mechanism.

The psychological causes of migraines are the most interesting, at least to me. Sacks breaks them up into the following categories

• recuperative: these tend to occur after a prolonged stretch of emotional and/or physical exertion, and are typically followed by refreshed feelings of strength and energy. One may think of recuperative migraines as a form of forced rest.
• regressive: "...regressive attacks are marked by pitiful suffering, dependency-needs, and cries for help. In a word, they assume the characteristics not of sleep, but of illness" (214).
• encapsulative: these migraines encapsulate painful feelings, transforming prolonged suffering into a relatively short migraine. For example, menstrual migraines can condense the stresses of the month into a migraine. The summation of pain might not change, but the duration is made much shorter.
• dissociative: you know that classic picture of an iceberg, where it's a lot bigger under water? This is the migraine equivalent. Some people are divided into two parts. One part is the public part that acts happy and well. The other is the private, and perhaps repressed, part, which revels in pain and suffering. This latter part is responsible for dissociative migraines. In other words, these migraines express some hidden or repressed emotional suffering.
• aggressive: these tend to happen when one harbors feelings of rage or hostility towards someone, but it is impossible to express these feelings in a normal manner. The migraine takes the place of a verbal or physical outlash.
• emulative: a sympathy migraine. That is, a migraine that emulates the sickness of someone else.
• self-punitive: mostly occuring in "deeply masochistic, spiteful, [and] chronically depressed" people. A form of self-punishment.

Thus, the particular interest of situational migraines, and their special strategic value to the patient, is that they represent biological reactions which can double as symptomatic acts or conversion symptoms. (222)

Therapeutic Approaches to Migraine

I guess the last section wasn't that short. Oh well, at least it was easier to write. It's mainly just copied content. Hopefully this section will be even easier.

This sections covers acute (stuff you take during the attack) and preventative (stuff you take to prevent future attacks) treatments. The history of migraine treatments is as follows. In the old days (~100 years ago) we didn't really know what caused migraines. So there were a bunch of drugs that did different things (e.g. targeted different neurotransmitters). This led to polypharmacy, where patients took five or six drugs in hopes of a therapeutic combination of meds.

Recently, we've discovered a bit more about how migraines work.

The most general hypothesis is that of Lance, who envisages the initiation of attacks in the hypothalamus, whether on the basis of a built-in periodicity, or in response to sensory stimuli from the cerebral cortex. Once initiated, impulses descend from the hypothalamus to the periaqueductal grey matter, thence to the raphe nuclei, and here, as we have seen, they can affect the cortical microcirculation, constricting it, initiating "spreading depression" in the cortex (and thus producing the aura phase of the attack), and at the same time reducing pain perception by closing the (enkephalinergic) "gate" in the spinal cord. (259).

With new understanding has come new drugs, which target more specific mechanisms than their predecessors.

As someone who has migraines (they might instead be chronic headaches, according to my neurologist), the drugs in this section were pretty recognizable. Off the top of my head, Sacks covers propranolol, amitriptyline, verapamil, and feverfew. He also covers stuff like accupuncture and biofeedback. Note that newer research shows that feverfew has adverse effects if taken over a prolonged period. Personally, I've taken topomax, indomethacin, propranolol, verapamil, and amitriptyline. Topomax was the only one that really worked, but I think I got too used to the drug because the headaches came back. These chapters show how wide the range of migraine drugs is, and how treatment may require large amounts of trial-and-error. I can definitely relate.

Migraine as a Universal

This chapter is a broad exploration on hallucination. It turns out migraine auras share many features with other types of hallucations (e.g. ones induced by mescal or weed). There are also some connections between chaos theory and migraine auras. I'm too lazy to write about it, and am also slightly unsure of my understanding, so that's all I'll say.

Finally Done

I don't think anyone will actually read this far, but if you have, congratulations! Your Amazon package will be arriving shortly.