Migraine UNDERSTANDING A COMMON DISORDER by Oliver Sacks MD University of California: $17.95; 270 pp., illustrated)

Since an estimated 10% of the population suffers from some form of migraine, it’s likely that you or someone you know have suffered from this enduring affliction. In this expanded and updated version of a book first published in 1970, Oliver Sacks, a professor of clinical neurology at the Albert Einstein College of Medicine in New York City, offers an erudite, literary and thoughtful medical treatise on migraine for lay persons and physicians, emulating some of the best in classic medical writing. His writing is informed by history and culture as well as science, filled with good critical evaluation of the field, and capped with a punch line that is far-reaching in its implications. Yet he is likely to arouse some antagonism within current neurological circles: He takes a somewhat anti-technological stance in his understanding of migraine and its treatment. For in contrast to many modern neurologists, Sacks comes across as either a classicist or a visionary--far behind--or far ahead of--his time.

In previous books Sacks showed that he could present neurological stories in an engaging way, talking about people rather than bundles of damaged neurons. The present work, in the same tradition, is based on his considerable clinical experience: Dr. Sacks has examined more than 1,200 patients with migraine, observing with a keen eye, getting to know his patients well, over time, and learning the ins and outs of this complex malady.

And complex it is! One strong message here is that migraine is not simply a headache, but a collection of highly variable physical and psychological signs and symptoms that differ from patient to patient, and often within the same patient over time. The common migraine that consists of severe, usually one-sided, throbbing headache and nausea is often accompanied by disorders of vision, sleep and arousal, mood, fluid imbalance, bowel dysfunction, and myriad other plagues. The “classic” migraine, which occurs in less than 1% of people, includes a premonitory aura, usually a perception of twinkling lights. But it may involve other unusual sensations, strange impairments of consciousness or abnormal movements. Sometimes the auras, nausea or other symptoms, occur without headache, and these phenomena, too, are regarded as migraine.

Indeed, so many manifestations of migraine are possible that the boundaries between what constitutes migraine (as “migraine equivalents”) and what constitutes other neurological and psychiatric disturbances such as epilepsy and hysteria are blurry. Perhaps Sacks can be excused for viewing the world through migraine-colored lenses; he sees migraine in places where others might not.

There are scores of clinical stories: Here are cyclic migraines that follow an internal clock, going off every month in premenstrual rhythms; here are previously persistent migraines, mysteriously interrupted for years by imprisonment in a concentration camp only to return upon release; here are migraines that run in families, and those prompted by exhaustion, or arousal, or heat, or cold, or alcohol, or noise, or music, or the monosodium glutamate (MSG) in Chinese food.

Or by an unhappy life. For although Sacks dispels the myth of a single “migraine personality,” he shows how migraines can become learned responses, triggered by cues of distress and conflict, becoming habitual when life circumstances remain problematic.

How to make sense of this? In Sacks’ view, migraine is best understood as a way we protect ourselves from a variety of noxious stimuli--whatever our personal poisons seem to be. At its simplest, migraine, it would seem, is one of nature’s ways of telling us to slow down, or to speed up, or to avoid exhaustion, or alcohol, or noise, or MSG. Beyond its ability to force physical recuperation by requiring the victim to lie down in a quiet place to sleep it off, migraine may serve other complex psychological functions: For some it may provide a way to be sick and signal the need for help; for others it may bind rage, conflict and anxiety that would be even more disabling if unbound; for others it may be a way of getting even, or of being self-punitive.

In short, migraine is a psychophysiological reaction that may have very different meanings for different individuals. Note that while this is helpful, it doesn’t explain why only some people protect themselves, or regress in this painful fashion. We still lack a comprehensive understanding of the hows and whys of migraine.

Sufferers who read Sacks’ section on treatment will know what they’re getting, or what they’re missing, from their physicians. In contrast with many modern physicians whom he sees as “pestering” active interventionists, through experience, Sacks has learned the virtues of patience, of trying to assess the meaning of the migraine for the individual patient and of offering simple tried and true remedies that go with the patient’s biology instead of fighting it. His therapy requires a lot of asking, listening and discussing--psychiatry and neurology both. He is not at all averse to using available medications, and he uses them well, but he has no illusions that any one medication will ever provide a “magic bullet” for migraine. He has learned that some patients do better keeping their migraines than trying to abort them, because the down side of attempts to short-circuit the attacks, such as prolonged depressions and malaise, may be worse than the few bad hours of headache.

One important caveat. This book is supposed to have been written primarily for lay people. Although there is a glossary to help the reader through some of the technical language, many may find the going tough. It’s also regrettable that Sacks neither expanded nor updated this excellent list of suggested readings since the first edition: The most recent was published in 1968.

But, all in all, if migraine concerns you, this book is worth browsing through, and if you can deal with the technical words, it’s worth reading thoroughly. You might also give copies to your physicians and ask them to explain the hard parts. You’ll all be better for it.