Barrett L. Dorko, P.T.

          Often in therapy we wrestle with intractable pain, that is, pain whose cause cannot be found or, if found, cannot be removed. Of course, this definition implies that to some extent the caregiver decides whether or not the patient's pain is intractable. When faced with such a situation, protocols, goal-setting, team meetings, and sophisticated functional assessments may not be as helpful as simply bearing witness with some depth of understanding and physiological insight.

          In Migraine, Oliver Sacks states, "Migraine is a remarkably primitive reaction involving massive alterations of vegetative activity and behavior." This description links the pain of a migrainous episode to instinct, for humans as well as all other mammals. Although it is not possible to say that animals have migraines, the behavior they exhibit in times of stress mirrors the migraine patient's withdrawal from the world.

          I'll get back to that, but I want to shift to something else.

          The Welsh poet David Whyte wrote a series of poems related to his prolonged periods of silent meditation. He begins "Imagine My Surprise":
                    Imagine my surprise,
                    sitting a full hour
                    in silent and irremediable
                    fear of the world

          Having felt this same fear in times of silence, I immediately relate to his words. Sacks points out that the mammalian reaction to the instinct of fear is two-fold, although the acute phase (flight or fight, sensory vigilance, and the emotional correlates of rage or terror) is usually the only one mentioned. Of equal importance is the physiologic and behavioral response to chronic fear (i.e., pallor, sweat, prostration, withdrawal, and immobilization). The emotional correlates are not described, but it is generally accepted that as fear spreads from the diencephalon through the human cortex, it may be mutated to a variety of emotions, or no emotion at all.

          Whyte's poem goes on:
                    to find the body
                    it's own fear the instant
                    it opened and placed
                    its unassuming hands
                    on life's enduring pain

          As the migraine sufferer withdraws, in fact, behaves as if irresistibly attacked, they create an opportunity for introspection, interoception (body awareness), and instinctive reactions unencumbered by human emotion.

          Perhaps they inwardly place their "unassuming hands" on their own fear. This ritual is usually very effective.

          Pain once considered intractable is entirely relieved and the patient often feels a surge of energy, the body completely reanimated. Maybe the underlying processes responsible for the attack are markedly diminished and difficult to reproduce, maybe not.

          Whyte completes the poem:
                    and the world for one
                    closed its terrifying eyes
                    in gratitude
                    "This is my body, I am found."

          Sometimes therapy helps those with intractable pain in a way that is like reciting this poem with the verses reversed. Give it a try.

Selected Reading
Sacks, O. Migraine. Berkeley, Calif: University of California Press.
Whyte, D. The Poetry of David Whyte, Langly, Wash: Many Rivers Press.

Suggested Reading
Dorko, B.L. The suppression of flight