Migraine: The Evolution of a Common Disorder

Sacks argues that migraine is a general disturbance of the brain—specifically, a slow excitation-inhibition-excitation cycle arising in the brainstem and projected onto the cerebral hemispheres and autonomic nervous system [citation:3][citation:15]. He rejects the reduction of migraine to a one-sided headache, emphasizing instead its sensory, emotional, and autonomic dimensions. A Nature reviewer summarized his model: the initial excitation phase produces prodromata and mood changes; the inhibitory phase manifests as withdrawal and suffering; the final excitation brings the sense of well-being during recovery [citation:15]. This unified biological account treats aura, vomiting, and post-attack euphoria as phases of one process, not unrelated symptoms.

Reviews were respectful but skeptical of the evidence. A Nature review called the theory 'agreeably comprehensive' but noted that 'the evidence which he presents in support of his views is scanty' and that the argument rests on his interpretation of rare clinical states bordering on epilepsy [citation:15]. The same reviewer found Sacks 'unjustifiably dogmatic' and criticized him for underrating biochemical research. A British Medical Journal review praised the book's 'detailed, learned and clear description' and its emphasis on migraine as a general biological disturbance, while finding the evidence for symbolic or conversion symptoms 'not impressive' [citation:3]. The consensus was that the book is original and penetrating but more a personal synthesis than a definitive scientific account.

Sacks had suffered from classical migraines and isolated visual auras since childhood. In a later letter to Neurology, he wrote that 'the extraordinary phenomena of the aura excited an interest in the brain at an early stage' [citation:6]. The book was drafted in nine days in 1967 while Sacks was working in a migraine clinic [citation:11][citation:17]. A study of Sacks's migraine writings notes that his auras had unusual features—starting in a dream, producing amusia, and involving olfactory sensations—that are rare in the neurological literature [citation:6]. His personal experience gave him an insider's perspective, but it also meant his account of migraine was shaped by an atypical case: his own.

The 1992 edition is 'revised and expanded,' with additional case histories, new findings, practical treatment information, and a new chapter illustrating color paintings by migraine patients [citation:2][citation:8]. Sacks's official website notes that the revised edition draws on advances in chaos theory and neural simulation, describing migraine as offering 'a most direct and privileged view' of neuronal organization and self-organizing systems [citation:11]. The original 1970 edition (University of California Press, 298 pages) was Sacks's first book; the 1992 revision (338 pages) reflects two decades of additional clinical experience and theoretical development [citation:1][citation:2]. Later editions were published by Vintage (1999) and Picador.

A British Medical Journal review found Sacks's contention that migraine symptoms can serve symbolic purposes—that they 'represent biological reactions which can double as symptomatic acts or conversion symptoms'—to be supported by 'not impressive' evidence [citation:3]. The reviewer did, however, credit Sacks for correctly rejecting the notion of a specific 'migraine personality.' A Nature review found the psychoanalytic discussion 'unnecessarily complex and indeed out of date' [citation:15]. These critiques target Sacks's willingness to entertain psychodynamic interpretations alongside his biological model. The book's strength, reviewers agreed, lay in its clinical descriptions and its insistence on migraine's biological unity, not in its speculative psychological extensions.

Migraine is the origin point for Sacks's lifelong interest in hallucinatory phenomena. His childhood migraines produced visual auras that 'excited an interest in the brain' [citation:6]. Hallucinations (2012) returns to this territory, with a chapter on 'Patterns: Visual Migraines' that addresses the geometric hallucinations of migraine aura within a broader survey of hallucinatory experience [citation:18]. Sacks's official website notes that his early migraine experiences, along with his 1960s drug experiences, 'launched a lifelong investigation into the varieties of hallucinatory experience' [citation:18]. The two books bracket his career: Migraine is the first book, a clinical monograph; Hallucinations is a late popular synthesis that draws on the same phenomenological territory.