“An important contribution to our understanding of the multi-dimensional process through which society perceives and construes pain and disability. Her study of headache and especially migraine powerfully demonstrates the way in which gender, stakeholder interests (including those of status-oriented physicians and profit-oriented pharmaceutical manufacturers), and the very elusiveness of pain interact to create that social entity we call migraine—an entity that shapes attitudes, self-perceptions, and access to care. Carefully researched and engagingly written, this study should be of interest to anyone concerned with the social aspects of medicine. And anyone who suffers from the curse of headache pain.”– Charles E. Rosenberg, Harvard University
Buy this book: Not Tonight
All in Her Mind
Migraine blurs the boundaries between mind and body in complicated ways. Take the story of Civil War Union general Ulysses S. Grant. On the evening of April 8, 1865, Grant’s army had finally cornered Robert E. Lee’s now exhausted Confederate army in Appomattox, Virginia. But Grant felt terrible. General Lee refused to surrender, and Grant was suffering from a severe “sick headache”— a condition that shares much in common with today’s migraine.
Grant got little rest as the armies settled down for the night.“I spent the night,” he wrote, “in bathing my feet in hot water and mustard, and putting mustard plasters on my wrists and the back part of my neck, hoping to be cured by morning.” Grant felt much the same the next day until he received a letter with better news: Lee had changed his mind. “When the officer reached me, I was still suffering from the sick headache; but the instant I saw the contents of the note I was cured.” With his headache gone, Grant met with Lee and negotiated a peace that would end the bloody war.
Grant’s vanishing headache dramatically illustrates the complicated interrelationship between mind and body in headache disorders. Anxiety or stress might exacerbate an underlying tendency to get migraine, but then, as in Grant’s experience, a turn of mood can abort even the worst attack. In contrast, for many people, migraine only comes during moments of relaxation. (Doctors used to call this phenomenon “weekend headaches” or “let-down migraines.”) Or migraines stay away during extreme stress, only to return in response to everyday aggravations. Joan Didion tries to explain these contradictions in her own migraines: “Tell me that my house is burned down, my husband has left me, that there is gunfighting in the streets and panic in the banks, and I will not respond by getting a headache. It comes instead when I am fighting not an open but a guerrilla war with my own life, during weeks of small household confusions, lost laundry, unhappy help, canceled appointments, on days when the telephone rings too much and I get no work done and the wind is coming up. On days like that my friend comes uninvited.”
The odd relationship between emotions and the onset and frequency of migraine is just one facet of how mind and body interact in migraine. The very experience of migraine can sometimes feel like a voyage to the fringes of the mental. This is especially true of migraine aura, which brings with it a diverse set of symptoms, some of which are surreal (hallucinations of sight, sound, and smell) and some of which are affective (elation, irritability, anxiety, or overactivity). Novelist Siri Hustvedt describes her auras as a“lunatic borderland” that provide pleasure, inspiration, and entertainment. Neurologist Oliver Sacks has mused that the fortification patterns he sees during visual aura might connect him to universal archetypes of human experience, noting that these patterns are the same as those used in the Alhambra, Zapotec architecture, bark paintings of Australian Aboriginal artists, and Swazi basketry. He suggests that the universality of these patterns might be rooted in the neuronal structure of humanity’s shared visual cortex, but the reader can’t miss the spiritual subtext of his essay. Lewis Carroll, on the other hand, envisions aura as magical and horrible. People in the headache community often say that his masterpiece, Alice in Wonderland, was inspired by his own experience with migraine aura. Some people with migraine, for example, experience the sensation of having body parts much larger or smaller than they actually are. Alice frequently feels the same way. After drinking the contents of a strange bottle, she says: “I must be shutting up like a telescope. And so it was indeed: She was now only 10 inches high.”
Not everyone finds these perceptual shifts as preternaturally romantic as Sacks, Hustvedt, and Carroll. An intense feeling of dread can also precede migraine attacks. Not infrequently, people with migraine lose fundamental language skills just prior to or during an attack. And treatment can complicate matters, as many medications used in the prevention and treatment of migraine have cognitive side effects including depression, difficulty concentrating, and forgetting words.
These examples demonstrate why Oliver Sacks has argued that migraine ought to be seen as a prime example of the“absolute continuity of mind and body.” Over the centuries, physicians have placed migraine in various positions along the mind / body spectrum. Headache experts currently consider migraine a somatic disorder rooted in the brain. But this is a break from the past. Up until thirty years ago, doctors primarily viewed migraine as having both a psychological and a somatic basis. In what follows, I trace these historical understandings of migraine from the nineteenth-century understanding of migraine as a disorder of upper-class intellectuals, to the influential concept of the “migraine personality” in mid-twentieth-century America, and finally to contemporary theories of comorbidity.
Each of these formulations describes the person with migraine as having particular qualities—that is, a distinctive moral character. And since moral descriptors tend to have gendered components, so do historical explanations of migraine. Of course, it is fair to say that any historical narrative of medicine will dredge up discourses that sound explicitly sexist by today’s standards. As cultural theorist Paula Treichler points out, analyses that accuse medicine of sexism tell us little that we don’t already know. Instead, she recommends analyses that interrogate how these representations of disease are “produced, disseminated, understood, and put to use” because they can help us contextualize how contemporary frameworks for understanding headache disorders continue to perpetuate stereotypical ideas about gender. In the account that follows, I pay close attention to how, at each historical turn, biomedical discourses come to enact and reinforce cultural narratives about gender, class, and pain via the encoded inclusion of moral character. After all, the credibility and the legitimacy of a disorder—and how much we, as a society, choose to invest in its treatment —is intimately tied to how we perceive the moral character of the patient.
Victorians and the Nervous Temperament
In Western medicine, headache disorders have long been understood as complaints that are rooted in the body but that maintain intimate relationships with emotions. Even as far back as Plato’s Charmides, Socrates refuses to give the hero headache medicine till first he had eased his troubled mind; body and soul, he said, must be cured together, as head and eyes. Galen, whose theory of “hemicrania” dominated medicine until the seventeenth century, speculated “certain natures . . . may end up suffering from headache if they lead an intemperate life.”
This association between headache and emotions persisted even as more modern physicians began to favor biological explanations of head pain. In the late seventeenth century, Thomas Willis (1621–1675), the “father of modern neurology,” wrote about migraine as a “nervous” disorder, locating the pain in the physiological structures of the brain. Yet despite this fundamental shift in how migraine physiology was understood, Willis warned that treatment of migraine in a patient would be “more difficult, if hypochondriacal, or hysterick.” Samuel Tissot’s (1728–1797) highly influential eighteenth-century treatise on migraine attributed the disorder to disturbed function of the stomach, but argued that this disturbance could be created by emotional and intellectual factors: James Mease (1771–1846), writing in 1832, agreed that the stomach was fundamental to understanding the disorder, but cautioned, “The passions of the mind must be kept under with especial care. Every mental irritation will add strength to the disease, and retard the wholesome operation of the remedies prescribed for its cure.”
References to mind and body, like the ones made by Willis, Tissot and Mease, were common in eighteenth-and nineteenth-century medicine. Victorian doctors, especially, made few distinctions between mind and body; it was simply assumed that emotions, mental impatience, lifestyle, and passions could affect, and even bring on, all sorts of disease. Because distinctions between mind and body were so rarely made, all of nineteenth-century medicine could profitably be described as psychosomatic.
The late nineteenth century witnessed the development of increasingly sophisticated theories about the physiological mechanisms of migraine. Physicians began to debate whether migraine should be attributed to disruptions in the nervous system or to dilation and constriction of the cranial vessels. But they agreed on one thing: the person with migraine had a“nervous temperament” that lent him an unusual intelligence, an active imagination, and a susceptibility to illness. This sensitive nervous structure produced a moral character that could be inherited from one’s family or cultivated through intense study. Nevertheless, the temperament was understood as an organic (somatic) phenomenon. How might this work?
Physician John Symonds (1807–1881) laid out a new framework for how a nervous temperament could exacerbate physical ills. “Say that a wasp has stung the dorsum of the foot,” explained Symonds in an 1848 lecture on migraine. “The pain may soon extend to the whole foot, or even the whole limb, without any corresponding extension of the local irritation caused by the wasp poison.” His point being that, in a normal person, pain can and does travel “sympathetically” away from its original source. But the nervous system of a “nervous” person is organized differently: “In different subjects there is a vast difference in the readiness with which these communications are made. Persons are called irritable, nervous, susceptible, hysterical, when the proclivities to such communication is very marked.” The nervous temperament, Symonds continued, did not affect all sectors of society equally. Rather, it tended to afflict “persons of very lively emotions and delicate sensitivity, easily perturbed mind, easily put off their sleep, [and] those who have the aesthetical and imaginative elements highly developed. It is also the frequent accompaniment and curse of high intellectual endowments.”
Symonds was repeating an old and well-accepted theory of nervous disease that had circulated for over one hundred years. In 1733, George Cheyne (1671–1743), a fashionable Scottish doctor in London at the time, wrote a widely read book, The English Malady, that explained poor health via degradation of the nervous system. Nerve strength guaranteed health. Nerves that were “too lax, feeble and unelastik” bred pathology and made one susceptible to environmental changes. For example, people with weak nerves felt “too much Pain and Uneasiness from cold or frosty Weather” and “too great a Degree of Sensibility or Easiness of being acted upon by external objects.” He blamed a combination of a heavy, unhealthy English diet; sedentary professions; and the hectic, noisy, and polluted London lifestyle for further burdening the weak nervous system.
Cheyne did not, however, see weak nerves as entirely unhealthy. The thinner and more fragile the nerve, the more quickly it could transmit a quality called“sense.” “Sensibility” conveyed aesthetic, intellectual, and social refinement, made one a “quick Thinker,” and provided the “most lively imagination.” Talented people were born with “organs finer, quicker, more agile, and sensible, and perhaps more numerous than others.” In contrast, “brute Animals have few or none, at least none that belong to Reflection; Vegetables certainly none at all.” Sensibility could be cultivated, but was also seen to be biologically rooted and inborn, determined directly by the exquisiteness and delicacy of one’s nerves. It was simply an unfortunate irony that refinement of nerves coupled so tightly with susceptibility to illness. People of good breeding, high sensibility, and excellent moral character were expected to come down with nervous disorders, like hysteria, hypochondria, or the “Vapours.”
Cheyne’s description of the nervous system and its disorders mirrored the clearly demarcated race and class boundaries of the time: the upper class with their weak nerves and sharp senses were biologically built for sedentary and intellectual professions, whereas the working class’s (and African’s) robust nerves and dull senses had the perfect build and aptitude for physical labor. But this logic presented a puzzle when it came to women, as they suffered from hysteria and other nervous disorders with greater frequency than men, but were not considered intellectually superior beings. Cheyne’s contemporary, Bernard de Mandeville (1670–1733), laid out this problem in A Treatise of the Hypochondriack and Hysterick Diseases: “Studying and intense thinking are not to be alledg’d as a Cause in Women, whom we know (at least for the generality of them) to be so little guilty of it; and yet the Number of hysterick Women far exceeds that of hypochondriack Men.” The answer, Cheyne argued, lay in their “Deficiency of the Spirits.” Women were simply born with weaker, finer, and more delicate nerves than men and, therefore, were not “made capable of running into the same Indiscretions or Excess of Sensual Pleasures” as were those born with “strong Fibres or Robust Constitutions.”
That women’s “delicacy” (in personality, tastes, and sensibility) was the result of their “delicate” nervous systems became firmly entrenched in both scientific and popular imagination. This “nervous temperament” will be immediately familiar to those who have read eighteenth-and nineteenth-century novels, many of which valorized sensibility and the nervous temperament. For example, Jane Austen’s Marianne Dashwood, the heroine in Sense and Sensibility, seeks a life filled with aesthetic pleasures and high culture. It is no coincidence that she is also of delicate constitution, having nearly died after walking in a torrential downpour. Her sensitive nervous system allows for superior tastes and intellect, but leaves her flailing with a weak constitution.
John Symonds’s 1848 lecture about the relationship between migraine and nervous temperament shared these gender and class assumptions. But he added a new dimension: “Such persons may also feel pains which have taken their origin from mere ideas.” And, thus, Symonds became the first— but certainly not the last — headache doctor to suggest in print that head pain might be caused entirely by suggestion. Or to phrase his contribution more accurately, suggestion could only bring on disease in a person whose body had already been weakened by “nervous temperament.”
The Lingering Nervous Temperament
Not long after Symonds’s lecture, two competing theories of the biological basis of migraine emerged, each with long-lasting consequences. Both theories identified migraine as biological, albeit positing different underlying mechanisms. Despite their biological orientation, however, both theories made ample use of highly gendered assumptions related to moral character. The nervous temperament remained a salient feature of migraine in the late nineteenth century.
The first theory posited that symptoms of migraine were due to vascular changes in cranial vessels. This was an ancient idea: physicians had implicated the vascular system in migraine since at least the seventeenth century. But in 1859, German physician Emil Du Bois Reymond (1818– 1896) renewed these theories with his observation that his own face paled during migraine attacks —the cause, then, must be the vasoconstriction of cranial vessels. In contrast, his compatriot, Möllendorf, noted in 1867, that his own face, as well as those of his patients, flushed during migraine attacks. Migraine, then, must be caused by either the expansion or dilation of cranial vessels. London medical lecturer Peter Wallwork Latham combined these two theories in 1873, arguing that Reymond and Möllendorf were both right. The migraine began with vasoconstriction, which would explain the visual and emotional symptoms preceding headache. But then the vasculature, exhausted by constriction, would over-dilate, causing the pain of migraine. He argued that his model could explain the varied expression of migraine symptoms:
It is well known that the vision is disturbed by a diminished supply of blood to the brain—as, for instance, in the faintness, which is induced by haemorrhage. The patients become giddy; everything appears dark before them; perhaps they have, moreover, flashes of light before their eyes, or noises in their ears, and then become insensible, and sink to the ground. How often do we hear from persons who are dying from asthenia such expressions as the following? “How dark the room is; “I can’t see”; “open the shutters”; telling us too plainly that the heart is powerless to drive the blood onward to the brain.
Latham concludes that, during this process,“The vessels become distended, the head throbs and aches, and the pupil contracts.”
The second theory, which reemerged as an influential text in the late twentieth and early twenty-first centuries, was forwarded by English physician Edward Liveing (1832–1919) in 1873. Liveing, said to have migraine, proposed a neurogenic theory in a thick treatise published the same year as Latham’s lectures. He argued that all headache disorders ought to be considered “megrim,” and, furthermore, that they are a close relative of epilepsy. His rationale was that the central cause of megrim had to be “a primary and often hereditary vice or morbid disposition of the nervous system itself” caused by an “irregular accumulation and discharge of nerve force” that would trigger a “nerve storm.” (Neurologist John Hughlings Jackson, his contemporary, had offered this explanation for epilepsy.) Liveing, moreover, rejected all vasomotor theories as inadequate to explain the myriad symptoms associated with megrim.
Contemporary neurologists consider Liveing’s treaty to be the real nineteenth-century innovation in headache medicine, but nineteenth-century physicians were dismissive. Latham, for example, was not at all happy with Liveing’s assessment of megrim as a close cousin of epilepsy — a disorder that had the hereditary taint of criminals, prostitutes, psychopaths, and homosexuals. Latham was pleased that his vasomotor theory would free migraine of these unfortunate associations: “If we take this [a vasomotor] view of the disorder, you will perceive that it has (as was first suggested to me by my friend Dr. Edward Liveing) a relationship, though happily a very distant one, to epilepsy.”
Both Latham and Liveing draw on the notion of the nervous temperament to various degrees. Latham described people with migraine as“possess[ing] what is called the nervous temperament; their brains are very excitable, their senses acute, and their imaginations free.” Latham encoded this excitability into his vasomotor theory and descriptions of the migrainous body. People with migraine, he argued, had a vascular system that mirrored their mental exhaustion. It also reflected their overall physique, lending them “a general want of tone —a relaxed condition of the muscular and arterial systems . . . the pulse being rather small and soft, often decidedly slow, but much accelerated on slight exertion or excitement.” Tension and “over-work” could cause the vasculature to constrict. Once the tension passed, the vasculature was likely to dilate.
Liveing’s references to moral character were subtler. Liveing argued that megrim was transmitted via heredity, which linked megrim closely to epilepsy, insanity, and other nervous disorders. But heredity, alone, could not bring on megrim. One would only inherit a disposition. Megrim required an additional “influence or combination of circumstances to call it forth.” Liveing argued that a person must engage in a behavior to experience migraine; thus, he concluded, people who experienced migraine would cluster in certain professions because of the conditions of their work— they were likely to be “a literary man, a barrister, a member of parliament.” His argument was sociological. If “overworked students, literary men, artisans, and [seamstresses]” were more likely to get migraine, then “depressing influences of various kinds” were to blame. “The malady often disappears again when the causes which determined it are removed.”
From a contemporary perspective, one of the most striking features of nineteenth-century writings on headache disorders is the extent to which most authors presumed a masculine subject, writing about the implicit migraine patient as“he” and including case studies of male patients along with the women. Nevertheless, most physicians understood migraine to affect more women than men, despite their references to barristers and members of Parliament. The extent to which this was true, however, was a point very much up for debate. In 1848, John Symonds reported the first quasi-systematic attempt to collect epidemiological data on migraine. His data, collected from hospital registrars and colleagues, found that seventy-six of ninety cases of “nervous headache” were female. “These numbers establish more strongly than I should have expected, the fact, which is testified by most of the old writers, that females are more frequent sufferers.” Liveing rejected Symonds’s statistics, arguing that “to make it trustworthy it ought to be shown that the cases were drawn from a miscellaneous body of patients in which both sexes were fairly represented. It is highly improbable that this was the case.” Liveing agreed that women were more likely to be affected with megrim, but estimated that a more fair gender ratio would be five to four.
It is, however, difficult to tell exactly what these physicians were measuring. Each had his own classification system for headache disorders, and variations across these systems could significantly change any measurement of prevalence and the corresponding gender ratio. For example, while Liveing considered a wide range of symptoms to fall under the category“megrim,” other physicians made distinctions between “neuralgic headaches,” “hemicrania,” “nervous headache,” “clavus hystericus,” and so forth. If women were systematically excluded from a single category like migraine, then epidemiological estimates of prevalence would include enormous variation. Substantial evidence suggests that, in fact, women who complained of headache were systematically given different diagnoses than men. Clavus hystericus, sometimes called “hysterical headache,” is the clearest example of a gendered diagnostic category in this time period. In his Treatises on the Diseases of the Nervous System, James Ross describes hysterical headache as a variation of hysteria: “Hysterical Headache is met with in females, and is generally accompanied by other symptoms of hysteria. This form of headache is on the one hand closely allied to trigeminal neuralgia, and on the other to true migraine. The pain is sometimes diffused and deep-seated, but it is more frequently limited to one spot, and feels as if a nail were being driven through the skull; hence it is called ‘clavus.’ Hysterical headache is increased in severity during the menstrual period and by mental worry, whilst it is removed by amusement and anything which engages the attention.” “Hysterical tendencies” could distinguish the pain of clavus hystericus from other headache disorders, although authors were usually vague about what, exactly, constituted these symptoms. In his 1888 monograph on headache disorders, Allan Mclane Hamilton suggests only one objective distinction: “Hysterical women are very apt to complain of very great diffused hyperaesthesia of the scalp, so that the simple act of brushing the hair causes great distress.” (This complaint might now be diagnosed as allodynia, which is a pain condition associated with migraine.) Knowing which of his patients had what Hamilton called “neuralgia,” which is described in his book as having a solid biological basis, and which were merely hysterical was important for treatment, as hysterics “are more apt than any others to form the opium habit, or that of alcoholism, and great care should be taken lest, by yielding to their demands, we foster something worse than the headache or hysteria.”
These arbitrary distinctions between nervous headache, neuralgias, and clavus hystericus in part reflected an evolution in how Victorians had begun to think about neuroses and the lines dividing mind and body. Traditionally, the nervous temperament and references to“nerves” more generally, did not, as we might think, automatically refer to psychological distress. Rather, these physicians were referring to a traditional and physicalist understanding of neurosis that had been handed down from the eighteenth century. Mental strain caused disease by way of weak and delicate nerves that became strained, stressed, and overstretched. But medical thinking on this topic was undergoing a massive upheaval during this time. Charles Darwin’s theory of evolution had made heredity a popular way of thinking about nervous disease. Thinkers like Alexander Bain and Jean-Martin Charcot drew attention to the influence of the will over the body.
As a result, mid-nineteenth-century discourses on nervous disease were often contradictory and incoherent. A nervous temperament indicated a weak nervous system. But nervous systems could be weakened because of the strong emotions conjured up by weak temperaments. This irreducible circularity begged a question: which came first, psychopathology or heredity? Headache doctors in the twentieth century had answers.
Copyright notice: Excerpted from Not Tonight: Migraine and the Politics of Gender and Health by Joanna Kempner, published by the University of Chicago Press. ©2015 by University of Chicago Press. All rights reserved. This text may be used and shared in accordance with the fair-use provisions of U.S. copyright law, and it may be archived and redistributed in electronic form, provided that this entire notice, including copyright information, is carried and provided that the University of Chicago Press is notified and no fee is charged for access. Archiving, redistribution, or republication of this text on other terms, in any medium, requires the consent of the University of Chicago Press. (Footnotes and other references included in the book may have been removed from this online version of the text.)