The Uprising of an Exhausted Brain—An Imperativist View of Migraine

Considering the prevalence of migraine and its impact on everyday living, its evolutionary persistence remains puzzling. This essay reviews recent literature and conceptual perspectives that frame migraine attacks as a possible side-effect of prolonged stress and unmet needs. To illustrate this, the article compares the antithetical relationship of triggers and migraine symptoms: During the early phase of the attack, many eat, drink, rest and sleep more and tolerate less nuisance compared to the hours and days before; previously, however, there was too little time to eat, drink, rest, and sleep, and the nuisance had to be tolerated. A relevant characteristic of many migraineurs is that they are prone to stress, e.g., because of a character trait, an impaired adaptation to stress, the lack of habituation to sensory stimuli, and disturbances of the energy supply. In that way, the appearance of the attack during fading stress makes sense: the body seizes the opportunity and communicates its needs when circumstances permit. In this context, the concept of pain as an imperative—a signal designed to enforce behavioural change—provides an insightful framework. Understanding migraine in this way may help reframe its pathophysiology and its clinical and translational significance.