For headache specialists, reducing the disorder to a specific mechanism in the brain doesn’t just relieve the symptoms of migraine [referring to development of Imitrex]; it also targets the stigma associated with it by shifting responsibility for the pain away from a weak or neurotic personality toward a body over which the patient has no control. In this, headache specialists are demonstrating a phenomenon known to cognitive psychologists, namely, that attributing low causal responsibility to stigmatized behaviors reduces blame and produces more positive feelings.
providing services to headache patients—no matter how needed they are—is often described as a money-losing proposition. The problem is twofold: headache medicine requires few procedures, while at the same time, necessitates long doctor-patient appointments. This matters because in the United States reimbursement rates pay much higher dividends for procedures than “evaluation and management.”
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.”