Macgregor: If you actually listen to everything or you read everything about managing headaches, you’d never be able to live at all, because people will be telling you that you can’t eat cheese, you can’t eat chocolate, you can’t drink any alcohol, you can’t do this you can’t do that — it’s all really, really negative.

Anne Hoffman: In popular imagination, migraines have become a woman’s illness, even though we know that migraines affect men, too. We know that doctors underestimate female pain – and

that could explain why we just know less about migraines. They aren’t studied as much as other chronic illnesses.

Throughout history, the causes and treatment of migraines have been linked to superstition.

In the middle ages, Hildegard von Bingen thought her migraine auras were visions—messages from God. She called them “reflections of the living light.” Her symptoms sounded similar to my own.

Around this time migraines also became associated with witchcraft.

Later on, in the 18th century migraines were tied to race and class. Wealthier people were thought to have more delicate nervous systems.

Joanna Kempner: You might be wittier, you might be more creative, more musical, more literary, but it came with this downside that you might get sick more often, you might be more fragile.

Joanna Kempner is a sociologist who wrote a book about migraines called Not Tonight: Migraine and the Politics of Gender and Health. And she lives with migraines herself.

Kempner: In contrast, people who were working class were thought to have more ropier, thicker nerves, actually physiologically ropier nerves, and those nerves made people sturdier and it meant that they didn’t feel pain as much but it also meant that they weren’t, they were like slower in thinking. And if you were a person who was from Africa the belief was that your nerves were so thick and ropey that you couldn’t feel pain at all. And of course, that would mean that you wouldn’t have very quick thoughts. So this whole notion of what nervous systems did and how they transmitted pain was a kind of basis for this race and class hierarchy and scientific notions of race.

And this idea grows in the 19th century.

Kempner: So people with a nervous temperament who have migraine, the elite and intellectuals, particularly men, are people who if you have a nervous temperament you might be creative, you might be able to think really quickly, but you might get struck by migraine if you do too much of that work. Like if you’re doing too much writing you might need to take a break because that will bring on a migraine.

Today we know that migraines mostly affect women. But one of the most influential migraine researchers focused mostly on men. His name was Harold Wolff and he’s considered the father of headache medicine. In the 1930s and 40s he developed a concept known as the migraine personality. And that’s an idea that’s still around today.

Kempner: The reason why he is revered in headache medicine now is because he was very scientific about understanding migraine. He did a lot of experiments, demonstrating that migraine was actually biological and linked to changes in cranial vasculature.

Wolff suffered from migraines himself. And it seems like he projected his own personality on to the disease. He worked at Cornell Medical School on New York’s Upper East Side so he mostly saw wealthy people. People who were highly successful, and hard-working. People like him.

Kempner: And so he started to think about people with migraine as ambitious, successful, perfectionist, and efficient. He thought they were good people, good moral character. And he thought they were linked to the cranial vasculature because these people get stressed out and their cranial vasculature would get tight and then when they finally were able to relax their cranial vasculature would get too big, it would expand, and that would be the migraine.

And so he would suggest to them that they should go play some squash every afternoon.

Kempner: Now he was mostly in that research, in his famous book that he wrote about migraine, he was mostly talking about his male patients, which I found interesting. I thought he was going to be talking completely about women. But in medicine, people, I found physicians mostly talked about their male patients and I think that this was fairly typical.

But here’s where things get even weirder…. He theorized that women with migraines were inadequate wives and mothers. He saw them as chronically unsatisfied housewives, incapable of completing socially-conscripted wifely duties. That’s right…. I’m talking about sex.

Kempner: He talked about them as frigid. When he talked about his male patients with migraine and their sex lives he also thought that they were sexually unsatisfied but of course he thought they had wives who wouldn’t have sex with them. So one of the things that I see throughout migraine medicine is that…this very gendered and really incredibly sexist way of saying that people with migraine, when they have problems the men it’s always about they’re using their brain, they’re studying too hard, they’re writing things that are too brilliant, and the women, they should just not be thinking at all and there’s something wrong with the way they have sex.

In the 1960s and 1970s there were panels full of physicians who openly talked about putting their migraine patients in psychiatric facilities. Women with migraines became women with mental illness.

So it’s not surprising that in our current era, Kempner herself was amazed to be treated with respect by doctors.

Kempner: So many years ago, when I was first getting into the field, I had become so accustomed to having my pain dismissed by physicians and so accustomed to having been treated like a neurotic woman that, when I went to my first headache conference, I was shocked to see that there were pictures of brains everywhere. I couldn’t believe that all of these headache doctors were taking migraine so seriously. I don’t know what I expected. Maybe I thought that they would all just be laughing at me. I was like, wow, look at all these people taking this pain I have seriously. It felt great.

But at the same time Kempner noticed that doctors talked about how people with migraines were different. They said their brains couldn’t handle things like changes in weather or estrogen.

Kempner: I was like, oh, I see what they’re trying to do. They’re trying to be helpful. But I was worried about that, and I didn’t think that, actually, it sounded much different than the things I was reading through history. So, It’s just the same metaphor. It’s always still about the person with migraine trying to protect themselves against these external forces. You’ve got to protect your brain against everything malevolent that’s happening around it.

And the thing about putting the causes of migraine on the individual is that it also puts the responsibility for solution or relief on the individual.

Kempner: So, migraine medication is advertised much like many other pharmaceutical ads with usually, almost always, it’s white women and they’re done up in such a way that you think maybe they’re much richer than you are.

Excedrin Advertisement: Migraines aren’t just bad headaches. They steal moments from my life.

This is an advertisement for Excedrin. There’s a white woman lying in bed. Rubbing her temples. The room is dark. Her cell phone beeps and it shows a photo of her husband and child.

Excedrin Advertisement: That’s why I use Excedrin. It starts to relieve migraine pain in just 30 minutes. And it works on sensitivity to light, sound, even nausea. All of it. It works fast and last for hours. Which is why moments lost to migraines are moments gained with Excedrin.

Kempner: By showing all of these women not doing the thing they’re supposed to do, like taking care of children or being there for their family or being at work, they’re really ignoring the fact that most people with migraine or most people with chronic pain are actually showing up all the time and doing their work and taking care of what they need to care for as best they can. Maybe it’s not always pretty and maybe it doesn’t always look great and maybe it’s not the way they want to do it, but people in pain are warriors.

Migraine ads play on this sense of guilt where women are supposed to be devoted wives, mothers and employees. Migraine robs them of this. Migraine medication is the answer. Even though we know no medication is perfect…. Not even remotely.

CHAPTER 3: A Historic Remedy

Alexis: Chapter Three. A Historic Remedy

Lisa: Most migraine drugs don’t actually stop migraines, they help prevent them, or reduce the severity of their symptoms. And for a long time they weren’t even specifically for migraines. They were drugs designed to treat high blood pressure, epilepsy, and depression. So you can probably guess that they are often not a perfect solution. Here’s Anne again.

Anne Hoffman: I take beta blockers. Beta blockers are an old-school blood pressure medication that also helps reduce the number of migraines for some people. Doctors aren’t sure why.

But they come with some undesirable side effects. Some of the ones I’ve experienced have been depression, weight gain, a slower heart rate, and an overall sense of moving more slowly.

So I started wondering if there wasn’t something better out there. Something without so many side effects. Maybe something unconventional.

One idea that I started hearing a lot seemed really promising. The only problem was that it was illegal. Or at least it exists in a legal grey area. That’s right. I’m talking about Pot. Ganja. Weed. Mota. Reefer. Cannabis.

Through a friend of friend, I met a woman who works in the cannabis industry in California. Her name is Ericka Kelly. Ericka suffered from terrible migraines since she was a kid. She told me the story of her first one. She was ten years old and her family was moving.

Ericka Kelly: I couldn’t even just do simple things like get little bags out from the car and take them into the house at all. I was completely debilitated. I remember feeling so bad cause my brothers were moving my stuff around.

Ericka’s family got her the best possible care. She went to the Mayo Clinic. She was in migraine studies. She was put on triptans. Until recently those were the only drugs that were just for

migraines. But they’re abortive rather than preventative, which means you can only take them to stop a migraine once you have one.

But nothing helped Ericka long-term. And when she turned 25, her migraines started getting worse. She started having cyclic vomiting syndrome. Her migraines spread to her abdomen. She’d throw up every twenty mins until she was so depleted, she had to go to the hospital.

Then someone gave her a cannabis tincture for anxiety.

Kelly: And so I was using it for that. But I didn’t even realize — like just after a while I noticed that my headaches were gone, that I just wasn’t getting them. It was like a month went by. And then two months and then six months and then a year and then two years and you know, up until now, I just, I do not get headaches anymore.

Ericka’s story made cannabis seem like a miracle drug. And she wasn’t the only one talking about it this way. I started thinking maybe I should try it too.

When I was talking to Anne Macgregor, the headache specialist we heard from earlier, I tentatively asked her about medical cannabis for migraines. And contrary to my expectations, she didn’t shut me down. She told me that it could be promising, either to prevent them or stop them after they’ve started. But then she explained a big caveat. Marijuana is a Schedule I drug in the US. It’s in the same category as heroin, which makes it really hard to study here. And the U.S. is where most clinical trials happen.

And Joanna Kempner told me the same thing:

Kempner: So the restrictions on clinical trials, for example, for medical marijuana are such that research has been essentially squashed and this has made it very challenging for people who want to use cannabis for migraine treatment. In headache medicine there is a growing consensus that cannabis is a very useful drug for migraine but we just need more research. And in fact I think the federal government would be doing everyone a great service if they would loosen these regulations and fund that research. Particularly since it’s going to be difficult to get pharmaceutical industries very interested in funding research on drugs that have existed for a long time.

Alexis: Hey guys, Alexis here. I just want to cut in for a moment to say that we could do a whole episode just about medical marijuana. We could do a whole series. We could devote an entire podcast in perpetuity just to this subject. But for this episode here’s what you need to know:

Lisa: The Cannabis plant is complicated. It contains hundreds of chemicals and they all do different things. Maybe. We actually don’t even know yet. But for this story we’re just going to focus on two chemical compounds: CBD and THC.

Alexis: Delta Nine Tetrahydrocannabinol, or THC, is the main psychoactive compound in cannabis. While it has therapeutic uses it’s best known as the part of the plant that gets you high.

Lisa: Cannabidiol, or CBD, is the second-most prominent compound found in the cannabis plant. And it’s all the rage right now. You’ve probably seen it on store shelves in the form of oils and tinctures, even in places where it’s not quite legal. People are excited because it seems like it may be an anti-inflammatory. And it’s now being touted as a way to treat chronic pain, anxiety, and a whole lot of other things. Back to Anne:

Anne Hoffman: Harvard Medical School says that the strongest scientific evidence for CBD’s effectiveness lies with treating what they say are some of the cruelest childhood epilepsy syndromes, which typically don’t respond to antiseizure meds.

Joanna Kempner says epilepsy and migraines are “close neurological cousins.” So I wondered if the fact that CBD can help with seizures means it might be able to help with migraines. I was hopeful.

And there have been a few small studies looking into cannabis for migraines. An Italian study found that after giving a small group of migraine patients CBD oil, with some THC, they reported slightly fewer migraines than the group who took an antidepressant.

Another small study in Colorado found that among 121 patients, the frequency of migraine headaches decreased with regular cannabis use.

There’s a lot of talk right now about CBD and its medicinal potential. And since I was pinning my hopes on it for my migraines, I wanted to understand how it worked scientifically. And I was surprised to learn that it’s not the only therapeutic part of the cannabis plant. It turns out THC does more than just get you high.

Margaret Heaney: THC gets you high and it also reduces pain and CBD, you know it’s not it’s not morphine by any stretch but it does you know it does reduce pain, and CBD we think is acting more as an anti-inflammatory.

Margaret Heaney is a cannabis researcher who teaches neurobiology at Columbia University Medical Center. She says that while CBD has pain-relieving potential, what people are buying at dispensaries and in stores might not be strong enough.

Heaney: So what’s being sold is often at a much much much lower dose than what any of us think is going to be medically effective.

Plus, many marijuana marketers claim to have CBD only products. But the reality is often very different.

Heaney: Some things will say CBD and have THC in them, and very little CBD, or you know it’s just, there’s people making money and it’s an unregulated marketplace so it’s not surprising to anybody that things are not going to be what you think they are.

Scientists know how THC works in the body, but they’re still trying to figure out exactly what’s going on with CBD.

Delta 9 THC binds to two places in our brains and our bodies: the CB1 and CB2 receptors. Its effects are quick. That’s why if you smoke a joint, you might all of a sudden get very happy, you might laugh, it’s a rapid process. CBD doesn’t seem to be working like that.

Heaney: CBD is still a very complex compound pharmacologically so it’s not it’s not binding to the same CB1 receptor seems to be binding to a bunch of other things so it’s much more complicated pharmacology.

And Heaney says it’s likely people need to consume CBD over time to feel its effects.

Heaney: So I actually am excited about CBD for a certain number of indications that I want to I want to see good research on. What the hype is far far far in excess of the reality.

The problem is that even though there is some good research on Cannabis and cannabinoids from the last twenty years, the legal limbo marijuana exists in has dampened scientists’ ability to do rigorous research. And that’s a loss, because cannabinoids seems to be good at treating one thing that is notoriously difficult to treat.

Heaney: the National Academy of Sciences really just has published an evaluation of all the science for all the different indications. People think of that cannabis might be useful for. And the top of the list and you know for which there is decent data is pain.

But there’s no indication of how much, when or in what form someone like me should take the drug. So there’s still work to be done to figure things out.

Alexis: It’s funny that Anne’s in the position she’s in because treating migraines with cannabis isn’t new. Not by a long shot. Chinese and Indian scholars commented on marijuana’s ability to treat neuralgic pain almost two thousand years ago. And the ancient Greeks wrote about its powers too.

Lisa: And nine hundred years ago our favorite feminist mystic-nun, Hildegard von Bingen, wrote about growing cannabis in the garden of the monastery where she lived, in a medical book she wrote called Physica.

Hildegard von Bingen voiceover: Hemp is hot. It grows where the air is neither very hot nor very cold and so is its nature. Its seed is salubrious, and good as treat for healthy people. Whoever has an empty brain and head pains may eat it and the head pains will be reduced.

Anne Hoffman: The first person to introduce marijuana to modern Western medicine in a major way was the Irish physician W.B. O’Shaughnessy. He experimented with cannabis in India, where the drug was commonly used. He experimented on animals and even children. But then he began using marijuana to treat rheumatism and cholera.

One property of the drug O’Shaugnessy noticed is that even if marijuana didn’t cure a patient, it seemed to lower his anxiety about illness. It also had strong analgesic, or painkilling, effects.

In 1890, John Russell Reynolds, then president of the British Medical Association, wrote that migraine sufferers should ingest hemp every day to prevent attacks.

Brian McGeeney: Cannabis was a legitimate medical treatment back then, as it was not just in Britain but in the United States. But we don’t have an institutional memory of that now.

Brian McGeeney is a neurologist and headache specialist in Boston. He also writes about the history of treating migraines with cannabis.

McGeeney: So what’s going on now is talked about a new thing, when really it’s a recurrence of something that was in pharmacies many many decades ago.

McGeeney says some form of marijuana was available in pharmacies in the US, Britain and France during the nineteenth and early twentieth centuries. In the second half of the 19th century you could get it in some grocery stores in the U.S.

He says there weren’t many good treatments for headaches then – and marijuana was value neutral.

McGeeney: Remember, at that time there wasn’t a political or cultural negative vibe about it like it is today.

CHAPTER 4: The Stigmatization of Marijuana.

Lisa: Chapter Four. The Stigmatization of Marijuana. Also, Racism.

Matt Crawford: One thing that’s interesting to think about is the concept of pharmacopeia. Which is essentially you know, the materials that a group of healers or society or culture has identified as those things that have medicinal properties.

Alexis: Matt Crawford is a historian of medicine and an associate professor at Kent State University. He was also a research fellow at the Science History Institute in 2017.

Matt Crawford: And pharmacopeias can take official form but some historians and scholars have started thinking about you know sort of informal pharmacopeias you know that a society or culture may not formally write down or produce but that exists right.

Lisa: Cannabis was entered into the United States pharmacopeia in 1850 as a treatment for a host of things, including cholera, rabies, alcoholism, opiate addiction, insanity, excessive menstrual bleeding, neuralgia, and virtually any disease that induced convulsions.

Alexis: But soon after that publishing its time in the sun started to fade. And as we all know, it’s no longer in our formal pharmacopeia. Although that may be slowly changing, as more states legalize medical marijuana.

Lisa: Its fall out of favor comes back to stigma. This time the racist kind. And behind it was a man named Harry Anslinger.

Alexis: Anslinger was the first commissioner of the Federal Bureau of Narcotics. When he took the job in 1930 prohibition was on its way out. And there’s speculation that he was worried that he’d be out of a job if he was only going after cocaine and heroin. So he wanted to make all drugs illegal, including cannabis.

McGeeney: He made it a mission and to try and get federal legislation against marijuana and he succeeded.

Lisa: Anslinger painted a picture that cannabis would make everyone who smoked it insane. This idea was echoed in the 1936 anti-marijuana propaganda film Reefer Madness. The film portrayed the drug as dangerous, and a gateway drug to heroin.

Clip from Reefer Madness: These high school boys and girls are having a hop at the local soda fountain. Innocently they dance. Innocent of a brand new deadly menace lurking behind closed doors. Marijuana. The burning weed with its roots in hell.

Alexis: Anslinger spread an anti-cannabis message that stoked people’s worst fears. Which brings us to his other argument about the drug. Based on racism.

Lisa: Anslinger preyed on existing racism and associated cannabis with Mexican immigrants and jazz, further stoking people’s prejudice. He racialized marijuana. And doing so has had lingering effects. What do most of us call the drug today? Marijuana. What did people call it before Anslinger? Cannabis. Many believe he used the Spanish word for the drug so it would be associated with Mexicans. The fear-mongering worked, and in 1937 Congress passed the Marihuana tax act. Here’s Anne MacGregor again.

Anne MacGregor: So that anybody who is actually using marijuana even for medical reasons had to pay a significant tax and therefore it just ceased being used as it then became recognized as a as a drug of abuse. It then went completely out of fashion because nobody wanted to touch it because there were those that the social connotation.

Alexis: It turns out how we think about drugs depends on who we think is doing the drugs.

Anne Hoffman: Beyond racism, there’s a theory Matt Crawford told me about that helps explain the stigma of cannabis. It holds that it encourages behavior that goes against our fundamental values as Americans and our puritan ideals. Hard work, reliability, devotion to religion and capitalism.

Anyone who has ever used cannabis can tell you that it does not tend to promote these behaviors. Here’s Matt Crawford again.

Crawford: Part of the problem with some of these psychoactive drugs is that they can induce a state of intoxication where you lose control of your faculties, right. You’re no longer a rational actor. I mean if you compare something like marijuana or opium to caffeine. Right. I mean that’s a drug that many of us consume every day on a daily basis. Why is that. Because it wakes us up. It gives us energy. Right. It it makes us good actors in a productive you know sort of capitalist society right. We’re ready to go into the cubicle and do our work.

Listening to Matt Crawford reminded me of what Joanna Kempner said about women failing to live up to their roles. And it got me thinking: when you take normal migraine meds you can go about your day. Or at least, that’s the hope. But what would happen if I tried cannabis for my migraines? In Pennsylvania, medical cannabis is now legal. But migraines aren’t a qualifying condition. I can’t just walk into a dispensary and buy it. In moments of desperation I’ve considered buying it on the street in Philadelphia, where I live.

But I know that the typical cannabis grown for street sales has been cultivated to get the user high, not necessarily relieve your pain. so I wonder how much it would help me. And I worry that if I went down this path I’d pay a price for getting rid of my migraines: I worry I would lose my productivity.

This fear isn’t unfounded, I’ve heard stories from patients saying as much.

The irony is that this ability to care less—including about their migraines—is actually something doctors WANT for migraine patients. That’s why antidepressants help them. The difference is that antidepressants usually make people more productive. Not less.

So what I need is for someone to hurry up and figure out which part of the cannabis plant and how much of it will bring me relief—without making me stoned.

But to get to this point it needs to be easier for researchers to conduct clinical trials. Here’s Anne MacGregor again.

Macgregor: Certainly it would seem totally logical for people to have access to a medicinal based, marketed, regulated compound that you knew had exactly the right dose with quality assured than it is for people to feel like they’re disappearing round corners to buy stuff off the street and then be ostracized for doing so.

Another problem with the long shadow of the drug’s stigma is that even in states where MMJ is legal, it’s politicians, not doctors, who get to decide which conditions qualify.

McGeeney: There are many states when medical medical marijuana was introduced it was really the lawmakers that were deciding what it could be used for and what it couldn’t. And maybe that’s a failure of the medical system because once we allow politicians to write indications, you know where you know who are we as physicians. And in order to appease the naysayers some of the states have very restrictive appropriate clinical indications for the use of cannabis. And it’s really a mockery.

Anne MacGregor said something that I thought was a really important point. Even without further research, we know a lot about cannabis already. Including about its safety:

Macgregor: You know what of the major factors is that medicinal grade cannabinoids have very few side effects. They’re safe. But the stuff you might buy from the unqualified people might not be safe.

CHAPTER 6: The Resolution

Alexis: Chapter Five. The Resolution.

Anne Hoffman: Back in March, a few days after I worried obsessively that I might lose my vision on the highway, my boyfriend Andy and I arrived in northern California. In San Francisco, I decided to check out a fancy dispensary while he stayed at our rental. The customers looked like a richer version of me. One guy was buying a few joints for a Friday night at home.

I talked to the owner. I told him about my migraines. He said he had the exact same condition. He recommended that I use a tincture of CBD with a little THC.

I was still deeply skeptical. But I was also increasingly desperate. I opted to part with $86 and buy the pricey little tincture.

Why not?

A few days later, on a cold night in San Francisco, the second migraine in as many days disabled my vision while Andy and I were trying to watch a documentary. I was terrified by the prospect of more pain.

For the first time ever, I tentatively placed one drop of CBD oil under my tongue.

That drop made my body feel warm all over. I felt grounded, slightly euphoric; and the pain in my face and head fell away in minutes.

The migraine cycle, which can last for days, just ended. Right there.

For the month that my little bottle of CBD oil lasted, I didn’t get any migraines. I can’t prove that CBD and CBD alone helped me. But I was ready to believe.

I’m in the process of getting my medical marijuana card—not for migraines, but for chronic pain.

As a migraineur, I’ve spent a lot of time searching in the dark for anything that can bring me relief. I don’t know why the drugs that work for me work. But I use them anyway, because not using them means living with a constant threat of terrible pain. Not using them would mean living a smaller and smaller life.

So I tinker, I read up on things, I experiment on myself, and I do the best I can. 900 years later, it’s not all that different from what Hildegard von Bingen was doing in the 1100s, in the garden of her medieval monastery.

For Distillations, I’m Anne Hoffman.

Alexis: So Lisa, we’ve covered a lot of ground. I mean, really, a lot of ground. So I mean what do you think? What are your thoughts.

Lisa: I just think it’s so fascinating that medical cannabis is something that’s very hot right now and the mainstream medical world is starting to investigate it and it’s literally thousands of years old.

Alexis: [Laughs] Right.

Lisa: We’ve known about it, we’ve known that it can help that it has therapeutic properties for thousands of years! But if you think about it it narrows down to this one very specific moment in time, the 1930s, this very specific law enforcement perspective has just cut us off from this whole area of investigation. We didn’t for decades and decades investigate the properties of cannabis. We pursued all these other things, all these other drugs got investigated, all these other pathways got investigated but not this one.

Alexis: We’ve spent all this time now rediscovering cannabis as treatment but it also feels like time wasted. Like why don’t we ever learn from the past and not throw away all of our knowledge? It feels like a bit of a waste to start from scratch every few hundred years or so.

Lisa: I also found it interesting as we went through that so many miraine researchers suffer from migraines. So this problem for them is so personal. And another thing this podcast often does is we try to break down that myth of objectivity. That science is personal, can be personal and in many cases should be personal. That’s what’s driving their passion for this. That’s what makes them want to find hope. And if anything, acknowleging that more can help break down the stigma we’ve talked about.

Alexis: We could talk about feminist nuns, migraines, and pot literally forever I think. Right?

Lisa: Definitely. But sadly we have to leave you! So tune in next time!

Alexis: And remember, Distillations is more than a podcast. We’re also a multimedia magazine.

Lisa: You can find our videos, blog, and print stories at Distillations DOT org.

Alexis: And you can also follow the Science History Institute on Facebook, Twitter, and Instagram.

Lisa: This episode was reported by Anne Hoffman.

Alexis: And it was produced by Mariel Carr and Rigo Hernandez.

Lisa: Jeanette Beebe was our fact-checker and Dan Drago did additional audio production.