CRASH!

Oh no. I developed a migraine within minutes of waking up Friday morning. What an ironic, self-fulfilling prophecy! There I was, patting myself on the back for going slow and building up nicely to a better fitness. I went to sleep contemplating booking a specific new travel adventure, thinking "oh yes, I'm good, I'm strong, I can do that, I'm up to it". So here I am, huddling in my (beautiful new) basement, away from the sunshine and construction noise next door, with the screen brightness turned down, feeling infinitely sorry for myself. I have migraine brain, meaning I'm thinking slowly and with difficulty.

This is the third crash in three months. The first time I know I went too far too fast. The second time, more cautious, I blamed it on hundred-degree weather. Now, I'm pretty sure I did this to me, not truly a physical cause. I should be able to fix this. Sure, it's all my fault, thinking this is how I got to this pickle in the first place.

Chronic pain and its nexus to emotional state is a very sensitive subject. There is a growing body of evidence that much chronic pain is not purely physical. For example, an examination of almost any middle-aged spine in this country will show physical deterioration, but not everyone with similar physical conditions experience pain at all. What is the difference between the responses? This is where the controversy starts.

There is one school of thought that much chronic pain is a physical response to suppressed emotional responses, often related to childhood trauma. Another school of thought leaves alone the emotional side and focuses on the central nervous system.  According to this line of thought, pain is a learned response, and the central nervous system is hyper-sensitive to any pain stimulation. Chronic back pain that lingers long after the initial trauma is resolved can be a learned pattern, for example. Both theories can be true at the same time - pain can serve as a useful mechanism for protecting someone, and then the response of feeling the pain can take over after the initial useful function is served. According to the thinking here, the solution does not lie in surgery or drugs, but in either or both of learning how to experience real emotions, and finding a way to break the hyper-sensitivity pattern. There are various formulations of talk therapy, mindfulness meditation, emotional writing exercises, combined with a graduated re-introduction of physical movement, with or without PT. Drugs are used in the short term for acute pain only - for example, muscle relaxants for back spasms, ibuprophen for inflammation, triptans for migraines. No maintenance drugs.This version of understanding chronic pain is still evolving, so there isn't a single term for it. Psychophysiological pain disorder (PPD), and mind-body syndrome (MBS) are the terms that I hear from practitioners I trust.

Many sufferers from chronic pain are outraged by this whole line of thinking. It ventures very near a blame the victim mentality, and at first glance appears to say "it's all in your head, just snap out of it". All the reading I've done on this subject tries hard to maintain a distinction. The pain is real. In an fMRI machine, there is no difference in the brain response between recent non-acute trauma and long-standing chronic pain. But all pain is subjective - it's all in your head. You feel pain. There is no objective measurement of its severity or acuteness - medical people have to ask, "On a scale of 1 - 10, what are you feeling?".  And of course there is a history in this country of doctors ignoring pain management and leaving pain untreated. And the adherents to the "fix chronic pain through mindwork" approach can feed this reaction. For instance, there is one school of thought that belief in the mental techniques is essential, so use of even short term pain killers shows a lack of belief, undermines treatment, and thus painkillers shouldn't be used ever. This is cult thinking: if mental magic doesn't work, the fault lies in the person who didn't believe strongly enough.

This debate strikes me as a bit similar to how thinking has evolved on healthful eating. In the 1970s, Dr. Atkins first suggested that cutting sugar and other carbs could lead to healthier outcomes than cutting out fat. He reveled in his rebel status and the medical establishment reviled him and his heretical diet, even proposing it was worthy of criminal prosecution. (Dr. Atkins died relatively young which even today people point to as evidence his diet is bad. The truth is the doctor died from a fall.) On the other hand, adherents to the Atkins diet had a religious reverence for him, very like a cult. No deviation from his written guidance. But now decades later, and only with great reluctance, more and more science has moved towards recommending eating more like the way Atkins suggested - fewer simple carbs and sugars, don't worry much about (good) fats. The doctor was more extreme, but there was a lot of truth in his proposals, but the medical establishment and the diet industry just didn't want to hear it. 

The modality I'm following for my chronic pain doesn't require absolute obedience to any doctrine. It involves a multi-pronged self-help approach of education, guided expressive and analytical writing, mindfulness meditation, guided visualizations, and self-talk (CBT).  As I've worked this approach from all the angles, I've had several useful realizations. One is that my pain has served me. When I was working, a back spasm or a migraine was an excuse not to go to work. I loved my work - truly - but it was stressful and my sense of responsibility made it hard to just take time off for me. Related, but also true and painful to admit, my pain allowed me to retreat from family obligations. I love my family (yes, even more than work) but it gets tiring being the responsible one. So my pain (painful as it is - haha!) gave me space from obligations.

So how are my crashes serving me now that I don't need an excuse to avoid work? I still have many (and joyful)  family obligations, and guilt  over retreating from the public square to be such a lotus-eater, so avoidance mechanisms certainly have their usefulness. But I think today's migraine comes from the adventure travel I was contemplating booking (though there is never a simple single cause for anything). I'm still on the fence on whether to go for the trip - expensive, complicated logistics to be sorted out quickly, doing it by myself takes lots of gumption - but when I first felt the headache I felt a twinge of relief with the unbidden thought, "I can't go". Sigh.

I did decide today to stick with my minimum baseline physical routine, despite the migraine. I put on my workout clothes, dark glasses and a hat, and went for a morning walk. It was tough with the migraine and I wasn't much faster than when I have my old dog slowing me down. I even needed to sit on a bench for a few minutes to calm the nausea. My heartrate was up as if I were running. When I got home, I drank two tumblers of water and I went down to the basement gym, where I fumbled through about half my normal routine in twice the time - but I showed up.

My thinking is that while I need to work on that overactive amygdala (visualizations are helping now) the body also needs to get stronger. So something is better than nothing in the physical realm. And to the extent my unconscious self is driving the symptoms, I don't want to reward unconscious-me with not having to exercise.

This afternoon, I'm off to a current events discussion group followed by some folks at a happy hour. Not sure about alcohol, but I want to not mope in the dark, quiet, basement all day. If the migraine persists, I'll take my triptan first thing in the morning.

Here are some links to reading and resources on the topic of chronic pain:

The Psycho-physiological Pain Disorders Association - great website
Institute for Chronic Pain
TMS Wiki
NYT first-person story about chronic pain - the comments are mostly people indignant at the suggestion one can manage pain with mind-work.
Excellent book on topic - Unlearn Your Pain by Dr. Howard Schubiner
App I'm using - Curable

Here is where I first wrote about my chronic pain:  Chronic