Attacks characterised by little more than malaise are likely to be regarded as mild viral illnesses. Attacks characterised by alteration of affect and consciousness—mild drowsiness or depression—may be taken for purely emotional reactions. Both

By what warrant, therefore, is such an attack to be termed an extended epilepsy rather than a quite brief and severe, let us say, a condensed migraine?

Characteristic of such affective equivalents is their brevity—manic-depressive cycles, as generally understood, occupy several weeks, and frequently longer. Monthly

Chorea—a twinkling movement or motor scintillation—does not have its origin in the cerebral cortex, but in the deeper parts of the brain, the basal ganglia and upper brainstem, which are the parts that mediate normal awakening. Thus these observations of chorea during migraine support the notion that migraine is a form of arousal disorder, something located in the strange borderlands of sleep—a disorder which has its origin deep in the brainstem, and not superficially, in the cortical mantle, as is often supposed (a

Compact and clearly defined at its center, migraine diffuses outwards until it merges with an immense surrounding field of allied phenomena. The only boundaries which exist are those which we are forced to adopt for nosological clarity and clinical action. We construct such boundaries and limits, for there is none in the subject itself.

Du Bois Reymond spoke of “a general feeling of disorder” at the very start of his attacks, and other patients speak, simply, of feeling “unsettled.” In this unsettled state one may feel hot or cold, or both (see, for example, Case 9); bloated and tight, or loose and queasy; a peculiar tension, or languor, or both; there are head pains, or other pains, sundry strains and discomforts, which come and go. Everything comes and goes, nothing is settled, and if one could take a total thermogram, or scan, or inner photograph of the body, one would see vascular beds opening and closing, peristalsis accelerating or stopping, viscera squirming or tightening in spasms, secretions suddenly increasing or lessening—as if the nervous system itself was in a state of indecision.

Far commoner, and perhaps the most intolerable of all aura symptoms, is intense sudden vertigo accompanied by staggering, overwhelming nausea, and frequently vomiting. The

fossilised” dream-sequences preserved as such in the cortex, precise replicas of past experience; they appear to be mnemic images which unfold, given the initial activation (epileptic, migrainous, experimental, etc.) at the same rate as the initial perceptual experience.

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.

It may, in its natural course, exhaust itself and end in sleep; the post-migrainous sleep is long, deep, and refreshing, like a post-epileptic sleep. Secondly, it may resolve by “lysis,” a gradual abatement of the suffering accompanied by one or more secretory activities. As

many cardinal characteristics of migraine aura, in its visual (scotomatous), tactile (paraesthetic) and aphasic forms. We

Many patients may confess that they feel “strange” or “confused” during a migraine aura, that they are clumsy in their movements, or that they would not drive at such a time. In short, they may be aware of something the matter in addition to the scintillating scotoma, paraesthesiae, etc., something so unprecedented in their experience, so difficult to describe, that it is often avoided or omitted when speaking of their complaints. Great

McKenzie once called Parkinsonism “an organized chaos,” and this is equally true of migraine. First there is chaos, then organization, a sick order; it is difficult to know which is worse! The nastiness of the first lies in its uncertainty, its flux; the nastiness of the second in its sense of immutable heavy permanence. Typically, indeed, treatment is only possible early, before migraine has “solidified” into immovable fixed forms.

PERIODIC MOOD-CHANGES We have already spoken of the affective concomitants of common migraines—elated and irritable prodromal states, states of dread and depression associated with the main phase of the attack, and states of euphoric rebound. Any or all of these may be abstracted as isolated periodic symptoms of relatively short duration—some hours, or at most two or three days, and as such may present themselves as primary emotional disorders. The most acute of these mood-changes, generally no more than an hour in duration, usually represents concomitants or equivalents of migraine aura. We may confine our attention at this stage to attacks of depression, or truncated manic-depressive cycles, occurring at intervals in patients who have previously suffered from attacks of undoubted (classical, common, abdominal, etc.) migraine.

Presiding over the entire attack there will be, in du Bois Reymond's words, "a general feeling of disorder," which may be experienced in either physical or emotional terms, and tax or elude the patient's powers of description.

Sudden fright, or rage, or other strong emotion may disperse and displace a migraine almost within seconds. One

The drowsiness which often accompanies or precedes a severe common migraine is occasionally abstracted as a symptom in its own right, and may then constitute the sole expression of the migrainous tendency. The

The hateful mood of a migraine—depressed and withdrawn, or furious and irascible—tends to melt away in the stage of lysis, to melt away with the physiological secretion. “Resolution by secretion” thus resembles a catharsis on both physiological and psychological levels, like weeping for grief. The

This state is thus one of an excruciating overall sensitivity, patients being assaulted by sensory stimuli from their environment, or

Thus it is awkward to call motion-sickness a migraine attack, but we may very conveniently term it a migranoid reaction, and note, in support of its affinities, that a large minority (almost 50 per cent, according to Selby and Lance) of adult migraine sufferers experienced severe motion-sickness in

Transient states of depersonalisation are appreciably commoner during migraine auras. Freud reminds us that “… the ego is first and foremost a body-ego … the mental projection of the surface of the body.” The sense of “self” appears to be based, fundamentally, on a continuous inference from the stability of body-image, the stability of outward perceptions, and the stability of time-perception. Feelings of ego-dissolution readily and promptly occur if there is serious disorder or instability of body-image, external perception, or time-perception, and all of these, as we have seen, may occur during the course of a migraine aura.

We have seen that there are two forms of stimulus which are particularly prone to evoke migrainous reactions in predisposed individuals: inordinate excitations or arousals, and inordinate inhibitions or slumps. Within certain “allowable” limits (which vary greatly from person to person), the nervous system maintains itself in a region of equilibrium, homeostatically, by means of continuous, minor, insensible adjustments; beyond these limits, it may be forced to react by sudden, major, symptomatic adjustments.

We may see very clearly how the wrong sound, or “anti-music,” is pathogenic and migrainogenic; while the right sound—proper music—is truly tranquillising, and immediately restores cerebral health. These effects are striking, and quite fundamental, and put one in mind of Novalis’s aphorism: “Every disease is a musical problem; every cure is a musical solution.

when the attack is “due” (or a little overdue), it will occur, explosively, whether or not there is any provocation.

Whichever method is utilised—violent physical, visceral, or emotional activity—the common factor is arousal. The patient is, as it were, awoken from his migraine as if from sleep. We shall further have occasion to see, when the specific drug therapies of migraine are under discussion, that the majority of these too serve to arouse the organism from a state of physiological depression.

You keep pressing me,” he said, “to say that the attacks start with this symptom or that symptom, this phenomenon or that phenomenon, but this is not the way I experience them. It doesn’t start with one symptom, it starts as a whole. You feel the whole thing, quite tiny at first, right from the start.… It’s like glimpsing a point, a familiar point, on the horizon, and gradually getting nearer, seeing it get larger and larger; or glimpsing your destination from far off, in a plane, having it get clearer and clearer as you descend through the clouds.” “The migraine looms,” he added, “but it’s just a change of scale—everything is already there from the start.” This business of “looming,” of huge changes of