The migraine mystery: Why evolution never cured the pain in our heads

Dated to around 1550 BC, during the reign of Amenhotep I, the Ebers Papyrus is actually a scroll running to about 66 feet in length, with over 100 columns of text describing various remedies for all manner of diseases and injuries. For what some readers have guessed might be rheumatoid arthritis in the shoulders or fingers, the document recommends forcing patients to vomit “by means of fish with beer,” and then bandaging their fingers with bottle gourd. To expel pain in “all the limbs of a man,” one 20th-century medical historian described the papyrus’s ancient healers recommending equal parts of honey, the mineral malachite, ammi (a flowering plant), styrax (a shrub), and what is translated as “dog’s excrement.” These are presumably mixed into a paste and applied to the patient’s face. “Do not lay hands on him,” the textbook reportedly advised.

As is often the case in Egyptology, the document’s place in the history of headache varies from account to account, and from one scholar to another. The scroll itself is a mix of magical and sometimes remarkably empirical thinking, and modern headache specialists have noted its sophisticated descriptions of the circulatory and nervous systems. For his part, Georg Ebers, the Egyptologist who purchased the scroll while traveling near the site of ancient Thebes, produced a two-volume facsimile of it in 1875 —­ complete with a hieroglyph-­to-­Latin glossary attributed to his colleague, the librarian and Egyptologist Ludwig Stern.

Two of the most recent medical histories focused on head pain, Mervyn J. Eadie’s 2012 Headache Through the Centuries and Katherine Foxhall’s 2019 Migraine: A History, each provide only a passing reference to the Ebers document, noting the difficulty in saying with any confidence that migraines were what the ancient Egyptian physicians thought they were treating —­ though it is roughly translated as a “disease of one-­half of the head.” Is that a reference to migraine? It can be difficult to discern, in part because the treatments are often the same for everything. Foxhall, a social and medical historian and now a local Green Party politician in the UK, points out that the instruction to anoint an aching head with “the skull of catfish, fried in oil or fat for four days was the same as was indicated for a thorn in the side, in order to draw the thorn out of the wound.”

Other researchers are less skeptical, even if they raise questions about whether translations of the Ebers text have mishandled the headache passages —­ including the remedy of fried catfish oil. One theory, for example, holds that the term “fried” might have been used poetically by the Egyptian scribes, who had in mind a species of catfish that would have been familiar to residents of the ancient Nile River Valley —­ one capable of delivering an electric shock. “With the patient having a severe migraine attack, why would the Egyptian healer want to take time out to fry up in [an] oil medium the head of dead fish which is already naturally oily anyway?” asked Rosalind Park in a chapter of the 2010 paperback Pharmacy and Medicine in Ancient Egypt: Proceedings of the Conferences Held in Cairo (2007) and Manchester (2008). Park posits that “fried” in this context may well have described an early form of electrotherapy, in which the high-­voltage zap of a catfish is used as an abortive, or at least a counterirritant —­ and “applied to the migraine sufferer’s head (once every) 4 days.”

Many headache patients today will no doubt recognize some resonance here with a modern category of medical devices used for therapeutic migraine treatment at home. These units are designed to deliver electromagnetic impulses to certain branches of the trigeminal nerve, the cranial structure responsible for the head and face, among other functions, or to the vagus nerve —­ a major communications pathway governing unconscious functions like breathing, heart rate, and digestion —­ as it passes through the neck. Other devices, applied to the back of the head, deliver a mild electrical current to the occipital cortex, a region at the back of the brain that is primarily responsible for processing visual information. Going by trade names like Cefaly and gammaCore (Catfish is apparently still available), these devices have been shown to help reduce the frequency and intensity of migraine attacks in some patients, and many fans swear by them. Still, as with nearly all remedies for head pain, real-world experience seems to vary.

Whether or not the ancient Egyptians were, indeed, early adopters of neuromodulation for the treatment of headaches is hard to pin down. What’s clear is that the Eber Papyrus’s description of a distinctly unilateral “disease of the head” —­ one of the most indelible characteristics of migraine and other primary headaches —­ rarely escapes mention in works tracing the history of these disorders, even if the document’s importance on the topic is sometimes overstated.

Other histories sometimes attribute entirely different migraine or headache treatments to the Ebers Papyrus, including one involving a clay figurine in the shape of a crocodile. According to this prescription, the reptile sculpture must have its mouth stuffed with curative herbs before being placed atop the patient’s head, where it is secured with a linen cloth. A former president of the American Headache Society recounted this ancient remedy and attributed it to the Ebers scroll as recently as 2005, in a textbook on migraines. That citation echoes one made in an earlier paper, dated 2003, suggesting that the crocodile treatment —­ also attributed to the Ebers Papyrus —­ may have “relieved the headache by collapsing distended vessels which were causing the pain.”

Setting aside whether an effigial crocodile strapped to the skull might help with a headache, Lutz Popko, a modern-­era translator of the Ebers Papyrus and a lecturer at the Egyptological Institute of the University of Leipzig, noted in a 2018 essay in the Bulletin of the History of Medicine that the remedy never really appears in the Ebers document at all. Rather, it springs from a specimen of somewhat later vintage called the Chester Beatty V Papyrus, which is held in the British Museum. It dates to 1200 BC.

Despite these misattributions, there seems little reason to doubt that the human animal has been dogged by excruciating, migraine-like head pain for a very long time —­ though precisely why and for how long remains a mystery. Several researchers, for example, have wondered why migraine hasn’t simply been relegated to the evolutionary dustbin —­ a disabling, pain-­generating burr in our genetic source code that, over millennia of self-­correction and fitness-­favoring, should have been long ago bred out of the species. 

It’s a compelling question, particularly given evidence that the portion of the population experiencing migraine and other headache disorders appears to be remarkably stable, neither ebbing nor flowing very much over time, and with only small variations across ethnicities and geographies.

This stability suggests that migraine and other idiopathic headache disorders are strongly influenced by innate genetic and neurobiological mechanisms, rather than being primarily driven by external environmental exposures. Migraine in particular has a significant hereditary component, with studies showing that individuals with a family history of migraine are at higher risk of having the disorder themselves.

Elizabeth Loder, an associate professor of neurology at Harvard Medical School, chief of the Division of Headache and Pain in the Department of Neurology at the Brigham and Women’s Faulkner Hospitals in Boston, and the head of research for the British Medical Journal —­ a true giant in modern headache science —­ surveyed several potential explanations for migraine’s genetic persistence more than two decades ago. Might the disorder be part of a latent defense mechanism, Loder wondered, with the pain possibly driving a self-­preserving retreat away from trouble and into solitude? Could it be that evolution’s natural favoring of quick and reactive nervous systems also delivered a few negative by-products that, while debilitating to certain individuals, weren’t enough by themselves to force a species-­wide adaptation? Maybe migraine is protective against some still-­unidentified pathogen, or perhaps the disorder is newer than we think, and we just haven’t had time to shed the trait?

It’s even possible, Loder speculated, that migraine —­ and I would throw in cluster headaches here myself —­ persists due to an inherent and inescapable communication conflict between the most primitive, most fixed parts of the primordial brain stem, and the more plasticky, more recently evolved structures like the neocortex —­ the largest and most advanced part of the cerebral cortex. “To draw an analogy to the computer world,” Loder writes, “such a mismatch between older and newer structures might be seen as akin to the difficulties that occur when one attempts to use the latest printer or fax machine with an older and less advanced central processing unit.”

I had similar conversations with Paul Rolan, the Australian clinical pharmacologist at the University of Adelaide. Rolan was among the early pharmaceutical researchers working on triptans in the 1980s, and he remains fascinated by the still-­hidden blueprint that allows for idiopathic human head pain.

“The records from ancient history seem to indicate these conditions have been with us unchanged, and yet there doesn’t appear to be anything similar in animals,” he told me. “I’ve never seen one of my pets lie in its bed with its paw over its head, sort of not working well. And the real question is why we got this, because first of all, it’s largely a young person’s condition. And usually, diseases that impair the productivity of your breeding population … have a winning disadvantage and tend to die out. So why is this so prevalent?”

Loder also notes in her monograph that Charles Darwin, the well-spring of modern evolutionary theory and the grandson of Erasmus, suffered from wrenching headaches himself. In his 19th-­century journals, documenting his wanderings aboard the HMS Beagle, the younger Darwin recounted several local remedies shared with him during a bad bout in Buenos Aires, Argentina. They were probably at least as effective as a clay crocodile tied to the head: “A common practice is to bind an orange-­leaf or a bit of black plaster to each temple,” Darwin noted, “and a still more general plan is to split a bean into halves, moisten them, and place one on each temple, where they will easily adhere.

“It is not thought proper ever to remove the beans or plaster, but to allow them to drop off,” he added, “and sometimes, if a man with patches on his head is asked, what is the matter? he will answer, ‘I had a headache the day before yesterday.’”

It has been easy for me at times to develop a jaundiced view of the headache’s distillation in the culture. Any pain disorder will do that to you, I’m sure, but pain in the brain breeds a special sort of cynicism, and I have to believe that it’s not uncommon to lose your sense of humor, even your sense of perspective, when the thrashing has gotten the better of you. Still, if the pain and associated symptoms of migraine and cluster headache often feel like heavy drags on the momentum of life, their lively presence across the span of time can be a compensatory joyride. What else can be said of Charles Darwin wearing wet beans on his temples?