Migraines were taken more seriously in medieval times – where did we go wrong?

This is a piece I wrote for The Conversation (08/09/2016) and which was subsequently republished in the Independent (17/09/2016). It is reproduced here under the terms of the Creative Commons Attribution No Derivatives license.

Katherine Foxhall, University of Leicester

Have you ever experienced a migraine? If so, perhaps you recognise this:

It feels as if there is hammering and pounding in the head. Sound or talking is unbearable, as is light or glare. The pain arises from hot, choleric fumes, together with windiness. And so one feels piercing, burning and ringing.

Such a precise explanation of the pain and disorientation experienced during a migraine might have been written yesterday. In fact, it comes from an encyclopedia, compiled by the Franciscan monk Bartholomaeus Anglicus (Bartholomew the Englishman), in the 13th century.

There aren’t many ailments that have maintained so clear a course over so many centuries. And what’s more, looking at the history of migraines reveals that the ailment was actually taken more seriously in the past, something we can learn a lot from today.

Hemicrania deciphered

We can pinpoint the beginning of the history of migraine as a named disorder to Galen (c. 129 – c. 216/17 CE), the most famous philosopher and physician in the Roman Empire. Galen set migraine, or hemicrania as he termed it, apart from other types of headache: as a painful disorder affecting only half the head, caused by the ascent of vapours from the stomach that were excessive, too hot, or too cold.

The 12th-century text of Causae et Curae, which scholars generally accept as the work of the the celebrated German abbess Hildegard of Bingen (1098-1179), gave a compelling explanation of why migraine seized only half the brain at a time: this was a bodily force so powerful, that if it seized the whole head, the pain would be unendurable.

An 18th-century portrait of Galen.

Although Galen’s writings were lost with the fall of the Roman Empire, Galen’s term, hemicrania, persisted, being adapted and adopted into various languages over the centuries. For example, in Middle English, we find emigranea and in medieval Wales the term migran. William Dunbar, writing in Middle Scots, used the term magryme in his poem describing the physical pain of migraine as being like an arrow piercing his brow, a pain so bad that he couldn’t look at the light. Dunbar also captured the migraine aftermath, the “postdrome” that came with the new morning, when he sat down to write but was unable to find any words. His head “dulled in dullness”, his body was unrefreshed, his spirit asleep.

Throughout the 16th and 17th centuries, a wealth of remedies in manuscript and printed recipe collections suggest a sophisticated general knowledge about this disorder. For example, Jane Jackson’s recipe book, dating from 1642, gives six separate recipes for “Migrim in the Head”, requiring various amounts of effort to produce. The simpler remedies could be made in a few minutes from common garden ingredients (mix houseleek and earthworms with flour, spread it on a cloth and bind to the forehead), but the most complex concoction required equipment, planning and financial outlay to produce a medicine that would last 20 years.

As well as taking migraine seriously, Jackson’s recipe book suggests that people of the 17th century appreciated that migraine could occur on a spectrum, from the occasional acute attack to a chronic illness that could last for several days.

Losing legitimacy

These historical descriptions of migraine reveal that we have lost something. In all of the sources from the medieval and early modern period that I have come across during the five years I have spent tracing the history of migraine, one thing is clear: these people took migraine seriously.

This is important. Migraine is now accepted as a “real” disorder which affects around one in seven people, two-thirds of whom are women, and is recognised by the WHO as the sixth highest cause worldwide of years lost due to disability (YLD). But despite this, it (along with other headache disorders) is nevertheless chronically under-funded, its sufferers often ignored, dismissed or blamed, and their ailments under-diagnosed and under-treated. In her recent book Not Tonight, the sociologist Joanna Kempner has described this situation as migraine’s “legitimacy deficit”.

So what has happened? Historical sources suggest that the question we need to ask is not how we can begin to give migraine the legitimacy it needs, but when and why we stopped taking it seriously in the first place.

‘La migraine’, 1823.

Over the course of the 18th century, something changed, as migraine became the stuff of ridicule. In May 1782, for instance, a flamboyant character graced the King’s Theatre Masquerade in London, and introduced himself to the gathering as “Le Sieur Francois de Migraine, Docteur en Medicine”. And in the summer heat of August 1787, the General Evening Post described how “half Paris had the migraine, and no lady of fashion could be prevailed upon to quit her boudoir”. Migraine was becoming something to joke about, a complaint that affected a particular kind of person, usually female.

By the 19th century, physicians routinely talked
of young female “martyrs”, and of sick headache and megrim as a disorder of “mothers in the lower classes of life” whose minds and bodies had been weakened by daily toil, disturbed sleep, insufficient nourishment and constant lactation.

Ring any bells?
Migraine Action

During the 1980s, many migraine sufferers took the opportunity to share their experiences of migraine by entering four international art competitions. The resulting collection, which includes over 500 pieces, reveals the powerful effect migraine has on people’s lives. Perhaps most striking is the frequency with which motifs such as arrows, hammering, pounding, light, glare and disorientation appear in this art – seemingly as familiar to sufferers today as they were to the medieval poets and physicians who discussed this disorder nearly 1,000 years ago.

For the first time, this collection is the subject of a dedicated website, which has now been launched by the charity Migraine Action as part of Migraine Awareness Week.

These paintings, backing up a thousand years of historical sources, make it clear that migraine is more than just a headache. It needs to be taken as seriously now as it was by Galen.

The Conversation

Katherine Foxhall, Lecturer in History, University of Leicester

This article was originally published on The Conversation. Read the original article.

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Making the Migraine Art Collection Public

Migraine Action is the national advisory and support charity for people affected by migraine, and is based just down the road from me in Leicester, UK. It provides support to individuals, families, businesses, medical professionals and support workers, with the aim to help sufferers to take control of their migraine and reduce its impact in their home life and in the workplace.

Migraine Action also holds a remarkable archive of around 550 original pieces of artwork which were produced by members of the public for four Migraine Art Competitions held between 1980 and 1987. Entrants were invited to illustrate their own impressions of visual disturbance or the effect migraine has on their everyday lives. The collection represents the work of around 450 artists, of whom three-quarters were women, and one in ten were children aged 16 and under.

Child detail

Detail of a Child’s Drawing. Reproduced with permission of Migraine Action.

Since the beginning of my project, I have wanted to include the art collection as a chapter in my book. While neurologists have considered the depictions of aura in these works to be useful in understanding something about the mechanisms of migraine, they have also dismissed the significance of the depictions of pain and lived experience. This seems wrong to me. Individually and collectively the artworks in the collection provide a vivid insight into life with pain and illness. Aesthetically many pieces of work – the hairstyles, the airbrushing, the net curtains, the cultural references – are very much a product of the 1980s, but the concerns represented by these artists often appear to be timeless. Depictions of daggers, hammers, flashing lights, pulsing veins, flames, social isolation, are as relevant now, as they were to the people who talked of migraine in the fifteenth or seventeenth centuries. But it is the images by children that I found most moving, and difficult to look at. I often wonder how a parent must have felt, after urging their child to draw a picture for the competition, but then having to see the results – their child’s view of pain, isolation and unhappiness.

As I have been working in the Migraine Action offices on my research, we have often wondered about how we could make this important collection more accessible to the public. The opportunity came earlier this year, when we successfully bid for funding from the University of Leicester REF Impact Development Fund, which aims to help researchers develop the public impact of their work.

The grant we were awarded has enabled us to employ a Research Assistant to catalogue and scan the collection, and to commission the Leicester-based social-enterprise design and communications agency We Are Epic to create a website which will give free public access to the entire collection.

The project began in earnest in early March, and the first task for Dr Steve Ling, our ReseAura detail 2Aura detail 3arch Associate, was to catalogue the entire collection. One of the most important aspects of this cataloguing has been the ‘tagging’ of images with keywords that will transfer to the website as search terms. Steve is now well into the high-resolution scanning. Seeing these images at such a large scale on the screen is wonderful, revealing the detail of every brushstroke and pen line.

Migraine detailMeanwhile, We Are Epic have been working hard on the website design. I am so excited about the ways that people will be able to search for images by theme and keyword. The website will be completed over the summer, and we hope to launch during Migraine Awareness week in September.

The historian’s research process is a long one, and it can be years before our results appear in print. This project has happened fast. It’s been so exciting to work with such an enthusiastic team on something that has such a clear and simple purpose. I can’t wait to share it with you all. More soon!

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Finding the Patients in the Notes.

It seems a long time since my summer immersed in the strange world of Anglo-Saxon and medieval medicine, and maintaining momentum on my research project is proving tricky halfway through a full semester of teaching mainly colonial history. Nevertheless, I’ve been spending a few days in the lovely Queen Square Library, home to UCL’s Institute of Neurology Library and the archival collections for the National Hospital for Neurology and Neurosurgery, originally the National Hospital for Paralysed and Epileptic when it first opened in 1860.

National Hospitals for the Paralysed and Epilectic.

The National Hospital for the Paralysed and Epilectic (from Building News, 1884) Courtesy of Wellcome Library, London.

The archives are home to the case notes of the physicians who worked at the National Hospital, a collection of approximately 1500 bound volumes dating from 1863-1946.

Although John Hughlings Jackson, William Gowers and their colleagues at the London Hospital must have often encountered patients with migraines, particularly when illness affected a patient’s ability to work, case notes specifically diagnosing migraine are relatively few among the volumes that discuss inpatient cases. It is clear, however, that patients who presented with migraine – particularly those who experienced distortions of vision – were of particular interest to Hughlings Jackson because their experiences offered insight into the relationship between the two sides of the brain. Migraine was one variation of a whole series of disorders that he believed could be caused by lesions in different parts of the brain. In his lectures and writings, Hughlings Jackson often used migraine as a footnote to illustrate a complex argument he was making with regard to epilepsy.

But medical casenotes are about more than the history of biomedicine. At particular moments of strain, they transcribe and immortalise ordinary people’s accounts, and their efforts to deal with, and understand the reasons for their illness. These are accounts of the everyday world which are usually left unrecorded.

A sixteen year old girl recounted her childhood; although she was always well-fed and clothed, her family had lived in a ‘very unhealthy’ house, draughty and damp, where the drains emptied straight into a stream. The girl said that she had sickness and pains in the head ever since she could remember. These had worsened when she started school, and increased again since she learnt to read.

One female patient explained that her pain was worse on the right side than the left. It often commenced with a flushing of her face and head, and she experienced noises in her head and ears that she described “like an engine letting off steam”.

Pulvermacher galvanic belts.

Pulvermacher galvanic belts. Credit: Wellcome Library, London.

Another woman described her attempts at self-treatment: “Has tried all kinds of diets, starving herself & lived once on toast & water for a month, but no good; taken patent medicines and tried Pulvermacher’s [galvanic belt] and other appliances but no good. Taken chlorodyne.”

Dr Gowers’ notes record the case of a 54 year-old deaf cab driver. After experiencing headaches, vomiting and dimness of sight for twenty years, the attacks had got suddenly worse in 1887, forcing him to give up work. He had been treated by Dr Beevor at Queen’s Square for six months, and his health had improved, but in early 1897 “he again commenced to have daily attacks & he has been laid up ever since”.

These cases are fascinating because they give such personal accounts of the experience of migraine and similar disorders in the nineteenth century. But they are also important because they represent rare institutional records of migraine treatment. These are real cases being treated by the men who were at the forefront of neurological knowledge in the nineteenth century. We know a great deal about these physicians, but very little about the medical practice, and the ordinary people that shaped their ideas.

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Why the Long History?

The heating in my office is back on, the students are returning to the flats next door, and the new academic year is rapidly advancing. Over the last few days I have found myself looking back over my summer of writing and thinking about my project as a whole, as I attempt to gather my thoughts and preserve my ideas, in the knowledge that until at least December, I will have precious little time to dedicate to writing chapters about migraine, as I turn my thoughts to teaching modules about Australia, migration and convicts.

Text page

British Library Royal 12 D XVII (Bald’s Leechbook) f. 7

Even since the beginning of the summer, the scope of my project has expanded far beyond my already stretched comfort-zone. Somewhat to my surprise I found myself spending much of July working on a chapter that begins in the tenth century with four remedies for ‘half’s heads ache’ in Bald’s Leechbook, and ends in the fifteenth century, with William Dunbar’s fantastic poem.

In early September I presented some of my work on migraine to the bi-annual European Association for the History of Medicine and Health conference, on the theme of ‘Cash and Care’. It was in many respects an excellent event – particularly the hospitality of our hosts – but I was shocked at how few papers considered any period before a very modern era, not least given the significance of the ‘medical marketplace’ scholarship over recent years. I began my own paper by talking about Linda Ehrsam Voigts’ work on the fifteenth-century banns of an itinerant medical practitioner, and joked that I had accidentally found myself working on the medieval period.

In the questions, a member of the audience commented that they had never heard of anyone trying to write a thousand year history of an illness before.

There is, perhaps, a reason for that.

And so since then, I have been thinking about this chronology: what am I trying to do? And why has this long time span come to matter so much to me, when many of my colleagues would consider it naively ambitious at best, if not simply impossible? Certainly, I cannot imagine a funding committee would have endorsed such a proposal when I began…

Historians have, of course, long advocated for paying attention to the longue duree. Fernand Braudel famously described events as ‘the ephemera of history’, as ‘surface disturbances, crests of foam that the tides of history carry on their strong backs’ . More recently, in their much-debated History Manifesto, the historians Jo Guldi and David Armitage argued that “historians once told arching stories of scale but, nearly forty years ago, many if not most of them stopped doing so. For two generations, between about 1975 and 2005, they conducted most of their studies on biological time-spans of between five and fifty years, approximating the length of a mature human life”. Guldi and Armitage identify a shift in our historical horizons. They have begun to expand once more, this time with the turn to ‘deep’ history. Medical historians have been among those diving in. In 2011 Monica Green urged historians of health to ‘go deep’ as well as ‘go global’ if we are to compete with the historical insights being produced in fields such as genomics & bioarchaeology.

My scale is not quite that expansive. For me, it is the availability of digitised material that has driven this chronology, sending a project that I had initially conceived as modern in scope, creeping ever further back through the centuries. A stream of highly fragmented, but extremely rich sources, has become navigable through online catalogues, digitisation projects and Google searches. Alongside bread-and-butter archival research, images of glittering medieval and early modern manuscripts – now freely available in high resolution – have repeatedly demanded my attention.

I will write more about the digital challenge soon, suffice to say that I have become acutely aware of the inbuilt distortions inherent to digitization that reinscribe hierarchies of class, race, gender & wealth privilege even while purporting to make archives ‘open to all’. My own project is geographically focused on Britain and Ireland, with glances across the English Channel and Atlantic to France and America. In the few cases where I discuss ‘global’ knowledge, I am aware that these are often ideas that have been appropriated by observers and collectors of the exotic in only the most superficial of ways.

13th century trepanation.

Mediaeval surgeon trepanning. 13th century.

Attempting a project of this chronological scale has proved a real challenge – not least in the amount of reading required to come even to the most basic understanding of any new era. As a colleague pointed out to me as I began to make plans, “You are not Owsei Temkin”. He was referring to Temkin’s magisterial Falling Sickness – his classic study of epilepsy, first published in 1945, which took readers on an odyssey through two millenia from ancient Hippocratic texts to John Hughlings Jackson, the nineteenth century ‘father’ of modern neurology. Temkin’s scholarship is staggering, but there are good reasons for looking at topics such as migraine over a long period, even if our attempts are on a far more modest chronological and intellectual scale than Temkin.

For a start it reveals surprising continuities. In many cases, medieval descriptions of the symptoms of ’emigranea’  as a piercing pain associated often with problems of eyesight seem closer to our own modern understanding of migraine with aura, than do eighteenth-century discussions in which migraine is associated with dizziness, unease, and seems to be – for want of a better word – altogether more fuzzy.

When we stretch out to a thousand years we see also that our current gendered pre-occupations, are far from inevitable – more of a blip, than the status quo. This is not to say that these assumptions are not deeply entrenched or that they will be easy to challenge. Far from it.

Taking the long view seriously, and populating the medieval, early modern, and modern period with a whole variety of people who experience, treat and discuss migraine takes us way beyond the old cliche of trepanation. It puts women back into the story as creators of knowledge, puts men back into the story as sufferers. Far from simply serving to reinforce a modern sense of superiority by highlighting the inadequacies of past knowledge, and the barbarity of practices long since abandoned, a long time span humbles our own knowledge, putting it into historical context. It emphasises the contingent nature of medical understanding, and the fragility of consensus.

Most of all, it is really really fascinating. I can’t wait to pick the chapters up again with a fresh set of eyes, when I get the chance.

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Oliver Sacks and Migraine’s ‘Strange and Riddling Landscapes’

We learnt earlier in the week of the death of the neurologist and prolific author Oliver Sacks. In February Sacks had announced that nine years after being diagnosed with an ocular melanoma, the tumour had spread, and that he now faced death.

There have been many heartfelt tributes to Sacks, who had a rare gift of writing about neurology in a way that appealed to millions. In studies on music, hallucinations, deafness, sleeping sickness, and migraine he mingled history, personal memoir and medical science to ponder the mysteries and marvels of the human brain.

I have only come to Sacks’ work relatively recently. No-one can spend much time on migraine without reading his seminal account, first published in 1970, and revised a number of times since. For Sacks, migraine was a disorder which struck particularly close to home. In 2008, in a blog for the New York Times Sacks talked of how he had experienced migraines, and particularly migraine auras, for most of his life. After experiencing his first aura at the age of 3 or 4, the young Oliver was reassured by his mother, a doctor, who shared her own experiences with her son. Years later, he went on to work in a migraine clinic, where he discovered more people who saw the same patterns that he did. Sacks mused that  perhaps “the geometrical hallucinations of migraine allow us to experience in ourselves not only a universal of neural functioning, but a universal of nature itself”. Such a comment reflected his fascination with the cultural importance – in art, folklore and religion – of neurological quirks, and the creative potential of ‘defects, disorders and disease’.

Sacks’ writings were united by his empathy for patient selfhood, his eye for a good story, and his ability to take meaning and wonder from the real-world lives of the people he encountered during his practice, lives so often assumed to be marred by loss, deficit and inadequacy.

In the revised version of Migraine Sacks added an epilogue in which he wrote:

“For every patient with migraine there is A Long Road, and a Short Cut. The Short Cut is a diagnosis, a pill, a pat on the head. It takes all of five minutes. There is nothing wrong with this. The only thing is – it doesn’t usually work. Hence the necessity, for many patients, to take the Long Road. The Long Road is the road of understanding – an understanding of the heart no less than the mind.”

Sacks certainly received criticism – from other neurologists and disabled people – for his ‘popular’ approach, and for the way he transformed medicine into literature. But the centrality of Sacks’ patients to his writing (Migraine, alone, contains over 80 case histories), and his appreciation for their journeys, sticks with me. As I continue to make my own way through the history of what Sacks’ called migraine’s ‘strange and riddling landscapes’ it is patient stories that I, too, hope will be at the centre of my work.

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On Elizabeth Garrett Anderson

In 1870 Elizabeth Garrett Anderson obtained her M.D. with a thesis on the history of migraine.

I’ve noticed Elizabeth Garrett Anderson popping up in my Twitter feed recently. On 29 September the Royal Society of Medicine in London are hosting ‘A celebration of Elizabeth Garrett Anderson and 150 years of medicine’, to commemorate the 150th anniversary of Elizabeth Garrett becoming a Licentiate of the Worshipful Society of Apothecaries. This made her the first woman in Britain to qualify for inclusion in its Medical Register.

In 1872, Elizabeth Garrett Anderson founded the New Hospital for Women, which was also staffed by women. After her death the purpose-built premises in Euston Road were renamed in her honour. Until 1988 it remained facility run by women, for women. The building is still a prominent feature on Euston Road, now part of the UNISON Centre and housing a gallery commemorating her achievements. Continue reading

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How migraine lost its legitimacy

In May 1782, a flamboyant character graced the King’s Theatre Masquerade in London. Gliding his way past the Venetian sailor, the gentleman in a coat of two different colours, and the usual unremarkable costumes of some eight hundred attendees, the High German Doctor cut a dashing figure. He introduced himself to the gathering as ‘Le Sieur Francois de Migraine, Docteur en Medicine’. Continue reading

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Diagnosing Hildegard of Bingen

‘The Heavenly City’, miniature from Scivias (c.1165), reproduced in Charles Singer (ed.) Studies in the History and Method of Science (Oxford, 1917).

In 1913, more than eight centuries after she died, Hildegard of Bingen got a migraine. During her life she had admitted to long periods of illness, but this was something quite new. Continue reading

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Oliver Cromwell’s Migraine

https://upload.wikimedia.org/wikipedia/commons/2/24/Oliver_Cromwell_by_Samuel_Cooper.jpg

Oliver Cromwell (1599–1658) by unknown artist. Reproduced courtesy of BBC Your Paintings. http://www.bbc.co.uk/arts/yourpaintings/paintings/oliver-cromwell-15991658-62668

On 23 March 1657, representatives of Oliver Cromwell and Cardinal Mazarin of France signed the Treaty of Paris, a surprising and uneasy alliance that would unite the two countries against Spain. In the weeks before the agreement, however, Cromwell had not been well: ‘Cromwell has a vertigo or migraine in his head, and fell twice on Sunday week’, correspondence from France revealed. Continue reading

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When bodies appear.

‘The head suffers from a certain internal pain which the physicians call migraine…It feels as if there is hammering and pounding in the head. Sound or talking is unbearable, as is light or glare’.

                        – thirteenth-century description of migraine from Bartholomaeus Anglicus, De Proprietatibus Rerum (On The Properties of Things) c.1245. Source: Faith Wallis, Medieval Medicine: A Reader (2010), p. 250.

I was reminded last week of one of my favourite books about bodies and illness. In The Absent Body Drew Leder asks a simple question: why, ‘if human experience is so rooted in the bodily, is the body so often absent from experience?’ (p.69-70).

Pain, Leder observes, makes our bodies appear to use, it reminds us of their presence. Pain ‘reorganizes our lived space and time, our relations with others and with ourselves’. Bodies that are normally silent, that we take for granted, seize our awareness at times of disturbance. Chronic pain, in particular, forces people into a constant dialogue (so often described in terms of battle) with their bodies. In the case of migraine this seizure is a deeply private one, invisible to those looking on. Leder’s book was one of the main reasons that I decided to look seriously into migraine’s history, to ask how, in different times and places, people have made sense of this often unfathomably painful intrusion of the body into their lives.

I first came across phenomenology several years ago. I am certainly no philosopher, but this way of thinking appealed because it is concerned above all with individuals’ relationships and interactions with their own surroundings. Phenomenologists recognise that people do not live in the world of rules and reasons conceived of by science, but in a much messier, more unpredictable world – the ‘lifeworld’. In his foundational book Phenomenology of Perception (1945), Maurice Merleau-Ponty described phenomenology as paying attention to “a general setting in which my body can co-exist with the world” (p.250). In another important text, The Poetics of Space (1958), Gaston Bachelard proposed analysing how people take root, day after day, in a “corner of the world” (p.4). The idea of the ‘lifeworld’ was not a new one. In 1934 Jacob von Uexküll had used the concept to explain how an animal’s existence is experienced through “meaning carriers”. These carriers of significance might include a sensitivity towards heat, or sound. Experience can also be affected by orientation, memories, preconceptions, fears and suspicions.

Pre-migraine

Debbie Ayles, ‘Pre-Migraine’. Credit: Debbie Ayles, Wellcome Images.

It is this emphasis on significance that I find most useful for thinking about the history of an illness such as migraine. This is not ‘environmental health’ in the way that we normally consider it, i.e. in terms of pollution and waste, but a much more personal and less tangible kind of relationship – in which noise, smells, light, changes in air-pressure or the phases of the moon are taken seriously.

One example of this that has stayed with me is a response to a Youtube animation of migraine aura (WARNING: this video contains black and white flashing images). In the comments posted below the video one woman described a time when she had experienced an aura while driving:

seeing multiple images such as repetitive road signs, lights from other cars coming at me while I was dizzy and not knowing if they were in my lane or not, and rays of colors shooting towards me all at the same time. Yes, I pulled over ASAP on a long, dark country road, scared to death and crying’.

People with migraine gain an acute awareness of their surroundings, As can be seen from this quote, and the excerpt I began this post with  this kind of environmental awareness has a very long history.

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