BOOK REVIEW

The Artful Chameleon: an exploration ofmigraine and medicine

Ed. A McComas.Dundas, ON, Canada: Alkat Neuroscience, 2007.€25.00. ISBN 978 1 894088 70 1

The Artful Chameleon is definitely not your typicalHeadache Medicine textbook. The Artful Chameleonis not multi-authored by a collection of interna-tional headache experts. Nor is it single-authoredby a headache expert. Rather, it is a book written bya neurologist with admittedly minimal professionalexperience in the field of headache. The author, DrAlan McComas, is a distinguished neurologistand Professor Emeritus Medicine (Neurology) atMcMaster University in Canada. He is best knownfor his work as a researcher in the field of neuro-physiology, where he is co-author of six textbooksand 170 peer-reviewed articles and textbookchapters.

The Artful Chameleon is not a typical HeadacheMedicine text with individual topic-oriented chap-ters. Rather, it is a story, partly autobiographical(highlighting briefly the evolution of Dr McComas’academic career in neurology) and, even more so,biographical. The real focus of the book is DrMcComas’ wife, Kate, and Dr McComas’ determi-nation to help his wife by better understanding herperplexing condition.

The book traces Kate’s neurological story over thecourse of five decades. The story begins with21-year-old Kate suffering from episodic attacks ofvertigo and headache that were diagnosed as ‘hys-teria’ by the local senior neurologist. The authornotes that he was ‘woefully ignorant’ as to the causeof his wife’s attacks and they were simply acceptedas an inevitable part of their lives. Subsequently,additional symptoms began to accompany theattacks, including visual disturbances, nausea andvomiting. Next, Kate is diagnosed with Meniere’sdisease and is treated with nicotinic acid. Years later,Kate is diagnosed with basilar migraine. Later, shedevelops a dull ache in her right lower jaw and isdiagnosed with atypical trigeminal neuralgia and,dramatically, but only transiently, responds to car-bamazepine and then radiofrequency ablation ofthe Gasserian ganglion. Kate’s story then becomeseven more atypical and bewildering. First, Katedevelops incapacitating lancinating migratory pains

throughout her upper torso. She then begins todevelop episodes that are associated with focalweakness, diplegia or tetraplegia. Hallucinationsbegin to accompany attacks. Finally, attacks intermit-tently become associated with respiratory arrestsrequiring cardiopulmonary resuscitation.

The dramatic and debilitating nature of the attackstake Dr McComas and his wife Kate on a therapeuticjourney through tricyclic antidepressants, b-blockers, calcium-channel blockers, acetazolamideand anticonvulsants. Many therapeutic modalitiesprovide benefit for months—but efficacy dissipatesover time. Non-conventional treatments such as ashot of whiskey, regular administration of meperi-dine and then meperidine self-injection are utilizedin a desperate attempt to mitigate symptoms.

Several neurologists are consulted and even aconsultation with the venerable Dr John Edmeads isdescribed. Eventually, Dr McComas turns to hisfriend and neurology colleague, Dr Upton, for atherapeutic trial of transmagnetic stimulation—amodality that Dr Upton is investigating for thetreatment of migraine. Thankfully for Kate and DrMcMomas, the transmagnetic stimulation providesdramatic benefit for Kate, rapidly aborting attacksand subsequently diminishing the frequency, inten-sity and complexity of her attacks.

The Artful Chameleon is unique and unconven-tional in that the book was, admittedly, born out offrustration with the general neurology and head-ache academic establishment. Kate’s case history, DrMcComas’ theories on the pathophysiology of hersymptoms and reports of her treatment responsefollowing transmagnetic stimulation were repeat-edly rejected by general neurology and headachejournals. The legitimacy of her symptoms and hercomplicated migraine diagnosis, the lack of neu-roimaging correlates, and the dubious significanceof a single individual’s therapeutic response to aninterventional treatment were repeatedly ques-tioned. In this book, Dr McComas criticizes themedical establishment, which in his estimation nolonger appreciates the value of a single case report,instead favouring epidemiological studies and basicscience investigations.

Throughout the book, the author attempts toexplain the possible pathophysiological underpin-ning of his wife’s symptoms. His theories are aprocess in evolution and they develop throughout

doi:10.1111/j.1468-2982.2008.01694.x

1343© Blackwell Publishing Ltd Cephalalgia, 2008, 28, 1343–1344

the book in parallel with the evolution of Kate’ssymptoms and her therapeutic successes and fail-ures. His research with transmagnetic stimulation isinitially an n = 1 ‘study’ on his wife and then, later,includes a second patient, Janet. Dr McComas con-cludes that migraines are the consequence of anunderlying cortical dysrhythmia or hyperexcitabil-ity. He likens a migraine attack to a forest fire—notone due simply to a cigarette or lightening strike,rather, one due to a ‘smouldering combustionunderground, which would periodically break outand ignite’. He acknowledges the likely role of thebrainstem neurons ‘policing’ the cortex in a similarmanner to the tonic inhibitory control within thespinal cord. Finally, Dr McComas speculateswhether transmagnetic stimulation may, likecardiac defibrillation, restore synchronous corticalfiring and, with it, the ‘normal balance of excitationand inhibition in the cortex’.

The debate over the genesis of migraine contin-ues in the headache literature, with proponents ofthe brainstem generator and the cortical generatorcontinuing to search for supporting evidence frombasic science and advanced imaging. Currently,larger-scale trials with transmagnetic stimulationfor migraine are underway. Irrespective of whethertransmagnetic stimulation becomes the standard ofcare for all migraineurs or whether it becomessimply a passing fad soon to be forgotten, The ArtfulChameleon carries with it several lessons whichwarrant mention.

Dr McComas reminds us that a limited 5-yearpubMed search does not allow one to review theavailable literature thoroughly. To facilitate a betterunderstanding of his wife’s condition, Dr McComasextensively reviewed the medical literature, and TheArtful Chameleon sites references from every decade

in the 20th century with numerous references toearly 20th century papers. Dr McComas doggedlysought out and reviewed original versions of Live-ing’s 1873 On Megrim, Sick-Headache and Some AlliedDisorders and Gowers’ 1888 A Manual of Diseases ofthe Nervous System. The story is complemented withsummaries of Sir Charles Symonds’ observation onfacial pain, Hallpike’s and Meniere’s observationson Meniere’s disease, Bickerstaff’s observations onbasilar artery migraine, and Melzack and Wall’sinitial observations on pain. Dr McComas possessesan obvious love of learning that has too often fadedinto the periphery in the hectic lives of most clini-cians. Dr McComas remarks how a library is ‘awonderful environment in which to work and, ifone truly loved knowledge, a very exciting one’.

The Artful Chameleon reminds the reader of theimportance of dogged determination in the pursuitof one’s goals. Dr McComas’ primary goal was tofind an effective treatment modality for his wife tominimize her pain and suffering; after 50 years, thisgoal was finally achieved. Dr McComas’ secondarygoal was to disseminate information about Kate’sstory. Despite numerous rejections from generalneurology and headache journals, Dr McComaspreserved and was finally rewarded with abstractsaccepted for poster presentation at the InternationalHeadache Society Congresses in Kyoto and Stock-holm and Kate’s story published in a full-lengthnovel.

Jonathan P. Gladstone, MD FRCPCDirector, Gladstone Headache Clinic

Director of Neurology & Headache Medicine, Cleveland ClinicCanada

Co-Director, Headache Clinic, The Hospital for Sick ChildrenToronto, Ontario, Canadajon.gladstone@utoronto.ca

1344 Book review

© Blackwell Publishing Ltd Cephalalgia, 2008, 28, 1343–1344