Abstract
We need to make sense of the world and act. To do this we construct models—bundles of descriptive and predictive assumptions. Since the time of the enlightenment in the 18th century, the traditional approach to scientific models has been based on reductionism. A system can be understood by breaking it down into its component parts and there is a simple causal relationship between the parts. The behaviour of the whole can be understood by the behaviour of the individual elements. In the world of headache, explanatory models come and go and the migraine phenomenon is reduced by committee into a collection of descriptive parts.
Lane and Davies challenge this model. The brain, they suggest, should not be thought of as a hierarchy of organized autonomous structures each delivering its output to the next in a linear function, but as a set of complex interacting networks that are in a state of dynamic equilibrium with the brain's environment. All types of headache are manifestations of the same underlying processes.
Drawing on a wide-ranging catalogue of detailed case studies, they highlight the many overlaps and intermediate forms of headache presentations and come to an inevitable conclusion—that migraine is not a disease, but a pathophysiological process; anyone can experience the symptoms if their genetically determined threshold is bridged; and that effectively, all headache presentations are part of a migraine spectrum.
Of particular interest to clinicians is the suggestion that many symptoms of migrainous origin, in particular aura without migraine, are frequently ignored or attributed to other causes. The section on aura is particularly illuminating, opening up new perspectives on patients who present with dizziness and funny turns.
The book starts with a detailed review of the history of migraine and how our ideas have evolved with time. The second chapter reviews the latest thinking on pathophysiology, and Chapter 3 draws upon a number of case histories to explore the phenomenon of aura and how it may account for a substantial proportion of otherwise inexplicable presentations. The next two chapters look at the complications of migraine and migraine variants, and Chapter 6 synthesizes the book's main theme—that all primary headaches are manifestations of migraine. The final chapters cover headache management and the delivery of headache care.
There are three criticisms of the book. First, the final section on headache management and service delivery go over familiar ground and seem rather incongruous in the context of the book. Second, at £110 the book is not going to attract the attention it deserves. Finally, although alluding to the possibilities of new models derived from the emerging science of chaos theory, the authors do not explore the opportunities of this new perspective in enough detail, particularly as it offers much support to their contention.
Most books on migraine are variations of the same recycled material. This book is refreshingly original, will ruffle a few feathers and challenge us on how we think about migraine. But is the truth out there? Probably not. Models are only at best approximations of the world, but some are more useful than others. This book challenges us to move on, to explore new models that may have more relevance to the complex, non-linear physiological mechanisms that underpin headache.