Book Commentary: Migraine by Oliver Sacks

Mary Stokes

Bio 245: Mental Health and the Brain

10 December 2008

Book Commentary: On Oliver Sacks’s Migraine, the Brain, and Mental Health

I have migraine.  I see a neurologist for the condition.  I have prescription medication that sometimes, sort of works against an attack. I sometimes try to avoid possible triggers: nutrasweet, red wine, too little sleep, too much stress.  I mainly just hope that I won’t get another migraine.

Oliver Sacks’s treatment of migraine exploded my succinct yet highly unsatisfactory view and experience of migraine outlined above.  Now I understand migraine within an open and evolving conversation about the brain’s solution to conflict, at the crossroads between physical and mental health.  Sacks challenges me--and his readers--to consider the migraine widely, “as part and parcel of the human condition,” as he has considered migraine in the context of a wide variety of patients and their lives.  As Sacks presents it, the migraine story is the story of the patients who experience it, and it is the story of the brain’s varied and often misunderstood interaction with the world.

In his introduction to the book, Sacks writes: “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 the psychophisiological reaction.  Thus the convergence of thinking which its understanding demands must be based, simultaneously, both on neurology and on psychiatry” (7).   Sacks thus approaches migraine with both the symbolic/emotional and physical perspectives in view—never veering too far into one realm before reconnecting to the other.  In this way, Sacks comprehensively addresses migraine as a product of a brain in which both emotional and physical stimuli interact.  He illustrates the connectedness of such brain phenomena, so that an emotional conflict can cause a physical, physiological conflict, just as a physical, physiological conflict can cause emotional turmoil within the brain and within one’s experience.  Some migraine may arise from largely emotional preceptors; other migraines may arise from physical, even chemical imbalances within the body and brain; other migraines result from the interaction of both types of stimuli.

Sacks structures his book in four parts: the first details the forms and symptoms of migraine as experienced by the patient and observed by the neurologist; the second explores the circumstances which provoke an attack; the third develops the mechanisms of migraine, both physical and psychological; and the final section explores migraine therapy.  Sacks builds each section, and his entire exploration of migraine, on case studies, or stories, from his migrainous patients—whom he calls “more instructive than any book” (xxvii).  These stories add both the meat and the flavor to the narrative—both the evidence on which Sacks bases his conclusions and the peaks of interest that make the narrative a captivating read.  

Besides making for an interesting and believable read, Sacks’ reliance on stories stresses the importance of personal experience and a patient’s story on their diagnosis and treatment.  No case study or story is exactly like another; indeed, where one course of treatment worked in one patient, it may fail miserably in another.  For example, in the case of the mathematician who experienced violent migraines each Sunday, when the pain was cured and the migraine eliminated, so too was the patient’s ability to do math; so while the goal of pain elimination was achieved—the desired end for many migraine patients--the treatment failed in its more costly consequence of elimination of genius.  In this case, the patient chose migraine over “cure.”  

As Sacks explores the how and why of migraines in his patients, he also explores how and why the brain acts as it does.  Sacks’ consideration of the aura phenomenon particularly illustrates how investigating migraine can shed light on the inner workings of the brain—even on the power (or lack thereof) of the consciousness or self’s ability to control or communicate with the brain, and vice versa.  Consider the case of a scotoma aura, in which portions of the visual field are obscured or entirely disappear, so that a “hole in the consciousness” arises.  At one time such conditions were considered “illusory” or “crazy,” but recent neuropsychological understandings of consciousness have begun to make sense of the holes, as present only in one’s “primary consciousness,” or in the “self”; this higher self can observe what is happening, “but is impotent to do anything about it.”  Sacks continues, “fortunately, such profound alterations of “self” and consciousness only last for a few minutes in migraine.  But in these few minutes one gets an overwhelming impression of the absolute identity of Body and Mind, and the fact that our highest functions—consciousness and self—are not entities, self-sufficient, “above” the body, but neuropsychological constructs—processes—dependent on the continuity of bodily experience and its integration” (98).  

The aura phenomenon speaks to the integration of the “self” and the unconscious, which generally function in continuity, so that we are unaware of a separation between the two, or at least of the power of the unconscious over the self; but in the case of the migrainous aura, the self has begun to construct a story somehow separate from the unconscious—one that does not reflect reality or at least continuity.  Such a phenomena has wider implications, too, into the cause of migraine—migraine as both a signal to and result of this lack of continuity and lack of communication within the brain.

 Migraine brought my own experience with a highly inconvenient condition into our Brain and Mental Health conversation about the bipartite brain and the most useful definition of mental health.  Sacks prompted me to consider how and why the brain produces a migrainous response, what that response means and how best to proceed.  Sacks’ reliance on stories convinced me of the necessity for physicians to understand (as much as they can) the full story of their patients’ lives—as initially irrelevant or separate from the condition they may seem.  In short, Migraine transformed my thinking as a migraine patient, a student of science, and as a future doctor.  

I had a migraine last weekend. I took my medicine, I went to bed.  The pain dissipated, but my vision remains blurry.  I still don’t know exactly why or how migraine is at work in my brain—but I think more about my story, how the stress in my life may have precipitated the event, how my bipartite brain may be trying to communicate within itself and with the world, and how to best proceed in light of this conflict.  I would love to put away the final exams and final papers demanding my mental energy; but I cannot,  So I trust my brain to regulate itself for its best performance—and if it must retreat for a bit during that drive, then I should let it go.  

Works Cited:

Sacks, Oliver. Migraine. Berkeley: U of California P, 1992.