Psychological explanations of migraine remain an extraordinarily popular trope in self-help books for migraine care. Take, for example, the most popular self-help book on this topic, Heal Your Headache: The 1.2.3 Program, by David Buchholz, a neurologist from Johns Hopkins School of Medicine. Buchholz recommends a strict treatment protocol for migraine prevention, which includes the immediate removal of all abortive drugs (i.e., the drugs that one takes to interrupt a migraine); a strict diet; and, if all else fails, preventive medications. The treatment plan is difficult to follow—he suggests that people quit taking their pain medications “cold turkey” without help from a physician, lest “you and your doctor … become entangled in a sticky web of victimization, dependence, blame and guilt …quick fixes … [that] undermine your determination to do what you can to prevent migraine.” If his methods do not work, Buchholz observes, “sometimes it’s hard to let go.” He confides that he is pessimistic about patients who are “entrenched in or seeking disability status, or pursuing a lawsuit, based on headaches.” Illness behavior, he explains, can help motivate migraine, as “when we’re sick, others give us their attention, concern, affection, sympathy, help, forgiveness, and permission to be excused from work and other responsibilities … our subconscious may have some other hidden agenda that interferes with response to treatment.”
Buchholz relies most heavily on psychological explanations of migraine when his recommendations fail to work for the patient. For him, the next obvious explanation is that the fault lies in the psyche of the person who refuses to get better. But it’s also important to remember that Buchholz isn’t talking about just any kind of person. He’s implicitly describing a feminized patient, one who could easily become involved in “victimization, dependence, blame and guilt.” Buchholz’s use of the psyche as a last-ditch explanatory model for the difficult patient underscores one remaining way that biomedicine manages the balance between mind and body in migraine: when patients— especially female patients—become “difficult,” the psyche remains a convenient explanation for treatment failure.
The embrace of biochemical approaches meant the corresponding rejection of psychogenic theories. … That the efficacy of a medication should erode a psychosomatic theory is not surprising. This is a fairly common phenomenon. Several disorders understood to be psychosomatic (depression or stomach ulcers, for example) were reframed as somatic with the discovery of effective medication. Yet in the case of migraine, ergotamine derivatives had been used successfully to treat the disorder for thirty-five years, yet had given a boost to theories of migraine as psychosomatic. Why did ergotamine promote psychosomatic theories, while methysergide eroded them? The answer is that methysergide worked as a preventative, eliminating migraines without changing the temperament of the patient. Raskin suggests this was an unexpected outcome when he says, “within a week they were headache free. No change in their internal milieu.”
He worried that so many migrainous women sought diagnostic tests and spent so much money on doctors when doctors had so few effective migraine treatments. The more appropriate role for the physician, he argued, would be to spend time with the patient, “in talking over her life problems and in showing her how to live more calmly and happily, than in making useless examinations.” “It is an axiom with me, he added, “that whenever a woman is having three attacks of migraine a week, it means that she is either psychopathic or else she is overworking or worrying or fretting, or otherwise using her brain wrongly.
…Wolff’s discussions of women and migraine were intriguingly limited, especially given that by then most physicians had agreed that women experienced migraines more often than men. Much like his Victorian predecessors, Wolff preferred to talk about headache disorders in the masculine. Likewise, his descriptions of migraine emphasized masculine anxieties about the rigors of work life.
If, as Foucault argued, modernity was the act of disciplining bodies, then Wolff’s migraine personality was discipline in its extreme—a pathological reaction to the corporeal demands of power. His subjects’ neatness and fastidiousness, he wrote, was exceeded only by their efficiency. People with migraine loved order and repetition, feared failure, and resented interruptions. They created elaborate “schemes, plans, and arrangements,” but “had great difficulty in complying with or adapting themselves to systems imposed on them by others.” The description of type A personalities varied depending on who had them. Women migraine patients who “worked” at home also wanted everything to be “just so,” but they had difficulty delegating even simple household tasks, like dishwashing, to housemaids.