Recommended listening: Classical music from Iran - Jalil Shahnaz in recital
Story
No medieval Muslim city was complete without at least one hammam. These communal bathhouses were often attached to mosques and were focal points of community activities. A place to purify, wash, socialize, enjoy sherbet, get a massage - the hammam served many functions. One of the most important of these was that the hammam was a place of healing. Doctors recommended the services of the hammam for treating a variety of ailments. One of these was the neurological disease known in Persian as shaghighe, and known to us in English as migraine.
Migraine has been recognised in medical literature for thousands of years. The English word comes from Ancient Greek ἡμικρᾱνίᾱ or hēmikrāníā, literally "pain in half of the head". Just like doctors today, however, ancient and medieval physicians knew that migraine was not merely a headache. Instead they recognised it as a full-body disorder which involves nausea and vomiting, visual hallucinations, vertigo, sensitivity to light, sound, and certain foods and smells, and a whole host of other symptoms. In the year 1000, Persian doctors, fully immersed in the scholarly environment of the period of scientific advancement known as the Islamic Golden Age, were on the cutting-edge of migraine treatment. They recognised that migraine could be triggered by exercise, changes in the menstrual cycle, or shifts in the weather. They also connected migraine to some of its rarer and most severe side effects like aphasia, the temporary loss of control over speech.
One of these doctors is ibn Sina, known in the west by his Latinized name of Avicenna. His Canon of Medicine was published in the early 11th century and shows a remarkable insight into migraine disease. This text was such a masterful treatise on medicine that it was still used in universities around the world in the 17th century. The greatest physician of his age, ibn Sina spent the latter years of the 10th century in Bukhara working as a doctor. He combined his own experience with the work of other, earlier Islamic and Greek physicians to compile his medical masterpiece. In the Canon, he divides migraine treatment into preventative care and rescue treatments during attacks. For preventative treatment he recommended an enema, while for treating the symptoms as they happened he prescribed a wide variety of medicines. Many of those medicines are still used in the treatment of migraine today, such as cannabis and opium - both of which he recommended only be used in the most severe of chronic cases, as they are today. He sometimes instructed for them to be ingested, and other times for them to be applied directly to the forehead. Ibn Sina's favourite recommendation for migraine relief was an application of mustard. Today, scientists recognise that mustard has an anti-inflammatory and analgesic effect.
The hammam was a crucial part of Persian migraine treatment plans. Ibn Sina recommended that when patients feel the migraine coming on - an experience described today as the prodrome and aura phases of migraine - they should take a bath and wash the head with water vapour. Patients would be aided in this treatment by trained hammam attendants, who were prepared to give their patients everything from bloodletting to a massage. He then suggested they force themselves to sneeze using pistachio oil. Other doctors also recommended the hammam in the post-headache phase of the migraine, known today as the postdrome. One medieval Persian physician recommended that patients at this stage receive several hours of foot massages, cold or warm compresses for the head, and the immersion of the limbs in tepid water.
The latter treatment is where we find the woman in this illustration. Today, migraine affects three times as many women as men, and many of the anecdotes about treating patients in medieval Persian medical texts are about women and girls. Women had equal access to hammams as men. In some cities, men and women had different days of the week they each could patronize the hammam, while in others they had different portions of the day. The entire staff would switch over from men to women when it was time for the women to come into the hammam. The hammam was an important part of women's social lives, and they would often show off incredibly elaborate jewellery and shoes after receiving their bath. Other women went with more serious goals in mind, whether it was purifying themselves for religious reasons or receiving medical treatment.
The bathhouse in Nishapur was one such medieval hammam. Nishapur was the second largest city in the entire Abbasid caliphate, second only to Baghdad. In the year 1000, it had roughly 150,000 people. Like many medieval Persian cities it was a cosmopolitan crossroads of many different cultures. There were Muslims, Christians, Jews, and other travellers and residents from all over Eurasia and Africa. Unsurprisingly, this caused Nishapur to become a hotbed of intellectual activity in the 10th century. One of the most interesting results of this intellectual climate is that it was in Nishapur that we find several examples of women leading intellectual thought in the development of Sufi mysticism. Women were deeply involved in the development and promulgation of Sufism in 10th century Nishapur. Their role has often been forgotten, but recently scholars have been working to recover just how important they were in shaping one of Islam's most important intellectual movements.
The flip side of this exciting intellectual climate was that Nishapur was also deeply divided between intellectual factions. The in-fighting of scholars in Nishapur drew the comments of visitors from other parts of the caliphate. All the highs and lows that such an academic world created must have caused periods of great stress for its participants, much as academia does today. And for some of the women involved in these debates, the added stress may well have triggered migraines. Persian doctors singled out stress as a possible trigger. They warned their patients to avoid skipping meals, eating and drinking too much, too much sex, anxiety, anger, loud noises, and talking too much, lest any of these things trigger a migraine attack. Anxiety, anger, and loud voices all must have been present in the lives of the early Sufi women and their day-to-day intellectual troubles.
In the hammam of Nishapur, patients needing migraine treatment could be escorted upstairs to the large pool. While other bathers enjoyed massages or gossiped over their sherbet, the woman in this illustration has been set up with a cold compress in the pool. The hammam's employees could control the temperature of the water, making it tepid as per the doctor's instructions. Perhaps they would have signalled to the other bathers that the usual laughter and other sounds of the hammam might be hushed today in appreciation of their patient's needs. Surrounded by the painted dados for which Nishapur is famous, the patient in her postdrome phase has a chance to close her eyes and pray that the pain will not return.
The seriousness with which Persian doctors took migraine is refreshing and eye-opening given the medical neglect plaguing many migraine patients today. Migraine costs the United Kingdom alone £2.25 billion a year in lost work days. It is the third most common disease in the world, with more sufferers than diabetes, epilepsy, and asthma combined. It is globally ranked as the 7th most disabling disease, and the most disabling of all neurological disorders. The World Health Organization classes migraine as among the most disabling illnesses in the world, comparable to dementia, quadriplegia and active psychosis. And yet, research into migraine is the least publicly funded of all neurological illnesses relative to its economic impact. No drug specifically designed to prevent migraine existed until the approval of erenumab in May 2018. Until then all preventative migraine treatments were off-label prescriptions for a variety of medicines ranging from antidepressants to anticonvulsants. Migraineurs frequently report being dismissed by doctors as drug-seekers and drama queens. We put up with incredible levels of dismissal and misunderstanding by doctors and laypeople alike, so many of whom don't understand how something that they see as "just a headache" can destroy so much of our lives. Recent breakthroughs in the development of CGPRs, or calcitonin gene-related peptide receptors, like erenumab are the first glimmer of hope in the history of Western medicine's disdain and ignorance about the severity of this condition. That the condition predominantly affects women is of course a factor in this disgraceful history.
The fact that ibn Sina, the greatest physician of the Islamic Golden Age, devoted so much of his energy towards figuring out the best treatments for his migraine patients shows that there are alternatives to Western medicine's reluctance to spend research funds on migraine. That he got so much right a thousand years ago is a remarkable testament to the dedication of medieval Persian doctors. I hope that his example can inspire the doctors today who try to help us cope with this terrible disease, and even more so that it inspires my fellow migraine sufferers by showing that the history of medicine, which has so often cast us to the side, has within it the potential to offer us the relief and care that we deserve.
Migraine has been recognised in medical literature for thousands of years. The English word comes from Ancient Greek ἡμικρᾱνίᾱ or hēmikrāníā, literally "pain in half of the head". Just like doctors today, however, ancient and medieval physicians knew that migraine was not merely a headache. Instead they recognised it as a full-body disorder which involves nausea and vomiting, visual hallucinations, vertigo, sensitivity to light, sound, and certain foods and smells, and a whole host of other symptoms. In the year 1000, Persian doctors, fully immersed in the scholarly environment of the period of scientific advancement known as the Islamic Golden Age, were on the cutting-edge of migraine treatment. They recognised that migraine could be triggered by exercise, changes in the menstrual cycle, or shifts in the weather. They also connected migraine to some of its rarer and most severe side effects like aphasia, the temporary loss of control over speech.
One of these doctors is ibn Sina, known in the west by his Latinized name of Avicenna. His Canon of Medicine was published in the early 11th century and shows a remarkable insight into migraine disease. This text was such a masterful treatise on medicine that it was still used in universities around the world in the 17th century. The greatest physician of his age, ibn Sina spent the latter years of the 10th century in Bukhara working as a doctor. He combined his own experience with the work of other, earlier Islamic and Greek physicians to compile his medical masterpiece. In the Canon, he divides migraine treatment into preventative care and rescue treatments during attacks. For preventative treatment he recommended an enema, while for treating the symptoms as they happened he prescribed a wide variety of medicines. Many of those medicines are still used in the treatment of migraine today, such as cannabis and opium - both of which he recommended only be used in the most severe of chronic cases, as they are today. He sometimes instructed for them to be ingested, and other times for them to be applied directly to the forehead. Ibn Sina's favourite recommendation for migraine relief was an application of mustard. Today, scientists recognise that mustard has an anti-inflammatory and analgesic effect.
The hammam was a crucial part of Persian migraine treatment plans. Ibn Sina recommended that when patients feel the migraine coming on - an experience described today as the prodrome and aura phases of migraine - they should take a bath and wash the head with water vapour. Patients would be aided in this treatment by trained hammam attendants, who were prepared to give their patients everything from bloodletting to a massage. He then suggested they force themselves to sneeze using pistachio oil. Other doctors also recommended the hammam in the post-headache phase of the migraine, known today as the postdrome. One medieval Persian physician recommended that patients at this stage receive several hours of foot massages, cold or warm compresses for the head, and the immersion of the limbs in tepid water.
The latter treatment is where we find the woman in this illustration. Today, migraine affects three times as many women as men, and many of the anecdotes about treating patients in medieval Persian medical texts are about women and girls. Women had equal access to hammams as men. In some cities, men and women had different days of the week they each could patronize the hammam, while in others they had different portions of the day. The entire staff would switch over from men to women when it was time for the women to come into the hammam. The hammam was an important part of women's social lives, and they would often show off incredibly elaborate jewellery and shoes after receiving their bath. Other women went with more serious goals in mind, whether it was purifying themselves for religious reasons or receiving medical treatment.
The bathhouse in Nishapur was one such medieval hammam. Nishapur was the second largest city in the entire Abbasid caliphate, second only to Baghdad. In the year 1000, it had roughly 150,000 people. Like many medieval Persian cities it was a cosmopolitan crossroads of many different cultures. There were Muslims, Christians, Jews, and other travellers and residents from all over Eurasia and Africa. Unsurprisingly, this caused Nishapur to become a hotbed of intellectual activity in the 10th century. One of the most interesting results of this intellectual climate is that it was in Nishapur that we find several examples of women leading intellectual thought in the development of Sufi mysticism. Women were deeply involved in the development and promulgation of Sufism in 10th century Nishapur. Their role has often been forgotten, but recently scholars have been working to recover just how important they were in shaping one of Islam's most important intellectual movements.
The flip side of this exciting intellectual climate was that Nishapur was also deeply divided between intellectual factions. The in-fighting of scholars in Nishapur drew the comments of visitors from other parts of the caliphate. All the highs and lows that such an academic world created must have caused periods of great stress for its participants, much as academia does today. And for some of the women involved in these debates, the added stress may well have triggered migraines. Persian doctors singled out stress as a possible trigger. They warned their patients to avoid skipping meals, eating and drinking too much, too much sex, anxiety, anger, loud noises, and talking too much, lest any of these things trigger a migraine attack. Anxiety, anger, and loud voices all must have been present in the lives of the early Sufi women and their day-to-day intellectual troubles.
In the hammam of Nishapur, patients needing migraine treatment could be escorted upstairs to the large pool. While other bathers enjoyed massages or gossiped over their sherbet, the woman in this illustration has been set up with a cold compress in the pool. The hammam's employees could control the temperature of the water, making it tepid as per the doctor's instructions. Perhaps they would have signalled to the other bathers that the usual laughter and other sounds of the hammam might be hushed today in appreciation of their patient's needs. Surrounded by the painted dados for which Nishapur is famous, the patient in her postdrome phase has a chance to close her eyes and pray that the pain will not return.
The seriousness with which Persian doctors took migraine is refreshing and eye-opening given the medical neglect plaguing many migraine patients today. Migraine costs the United Kingdom alone £2.25 billion a year in lost work days. It is the third most common disease in the world, with more sufferers than diabetes, epilepsy, and asthma combined. It is globally ranked as the 7th most disabling disease, and the most disabling of all neurological disorders. The World Health Organization classes migraine as among the most disabling illnesses in the world, comparable to dementia, quadriplegia and active psychosis. And yet, research into migraine is the least publicly funded of all neurological illnesses relative to its economic impact. No drug specifically designed to prevent migraine existed until the approval of erenumab in May 2018. Until then all preventative migraine treatments were off-label prescriptions for a variety of medicines ranging from antidepressants to anticonvulsants. Migraineurs frequently report being dismissed by doctors as drug-seekers and drama queens. We put up with incredible levels of dismissal and misunderstanding by doctors and laypeople alike, so many of whom don't understand how something that they see as "just a headache" can destroy so much of our lives. Recent breakthroughs in the development of CGPRs, or calcitonin gene-related peptide receptors, like erenumab are the first glimmer of hope in the history of Western medicine's disdain and ignorance about the severity of this condition. That the condition predominantly affects women is of course a factor in this disgraceful history.
The fact that ibn Sina, the greatest physician of the Islamic Golden Age, devoted so much of his energy towards figuring out the best treatments for his migraine patients shows that there are alternatives to Western medicine's reluctance to spend research funds on migraine. That he got so much right a thousand years ago is a remarkable testament to the dedication of medieval Persian doctors. I hope that his example can inspire the doctors today who try to help us cope with this terrible disease, and even more so that it inspires my fellow migraine sufferers by showing that the history of medicine, which has so often cast us to the side, has within it the potential to offer us the relief and care that we deserve.
Artist's Comments
I researched this one awhile ago but figured that June would be a good time to do it because it's Migraine Awareness Month in the US. It was cool learning more about Nishapur - all of these places I had never heard of which were in fact extremely important in the Middle Ages! That's exactly why I do this project, because I want to expand my knowledge beyond what my formal education gave me. This piece took many, many hours to work on because of the dado panel. It's based on a real example from the bathhouse of Nishapur. The woman's necklace is inspired by the one worn by a bather in the famous mural of Qusayr 'Amra in Jordan. The reflections on the water didn't come out as cool as I imagined, and the scanner ate the greenish colour of my turquoise coloured pencil that I used on the water. But overall I like the effect of the illustration.
For those who don't know, I have chronic daily migraine. I've had it since I was a child, around 12 or 13. Unfortunately, in the past four years it's gotten much worse, and I present with many rare symptoms and co-morbid conditions. I'm on erenumab and several other medications which are helping with my quality of life, but I still have a migraine every day and am hoping for new medical breakthroughs. I normally don't talk about my specific health conditions on my Women of 1000 site, but this project is one of the main things that helps me cope. Looking at the map, reading up on different places, sketching in my notebook, or just daydreaming about women in faraway places and times helps get me through.
This is the first explicitly disabled woman I've included in my series so far. I have been doing lots of reading about disability and archaeology, so I am hoping to bring you more stories of disabled women soon. We deserve to see ourselves in historical reconstruction art too!
The dado panel's repetitive geometric patterns of straight lines might have exacerbated my own migraines if I were in this picture, and they also bear some resemblance to scintillating scotoma migraine auras. Like my dad said while seeing this picture, it's sad looking at it and thinking she has a migraine. But I really wanted to show that this disease I have has a long history of being taken more seriously than it often is today. ~ June 30, 2021
For those who don't know, I have chronic daily migraine. I've had it since I was a child, around 12 or 13. Unfortunately, in the past four years it's gotten much worse, and I present with many rare symptoms and co-morbid conditions. I'm on erenumab and several other medications which are helping with my quality of life, but I still have a migraine every day and am hoping for new medical breakthroughs. I normally don't talk about my specific health conditions on my Women of 1000 site, but this project is one of the main things that helps me cope. Looking at the map, reading up on different places, sketching in my notebook, or just daydreaming about women in faraway places and times helps get me through.
This is the first explicitly disabled woman I've included in my series so far. I have been doing lots of reading about disability and archaeology, so I am hoping to bring you more stories of disabled women soon. We deserve to see ourselves in historical reconstruction art too!
The dado panel's repetitive geometric patterns of straight lines might have exacerbated my own migraines if I were in this picture, and they also bear some resemblance to scintillating scotoma migraine auras. Like my dad said while seeing this picture, it's sad looking at it and thinking she has a migraine. But I really wanted to show that this disease I have has a long history of being taken more seriously than it often is today. ~ June 30, 2021
Resources
Want to learn more about medieval Islamic migraine treatments or about the women and bathhouses of Nishapur? Here are some recommended resources.
"A review on the management of migraine in the Avicenna's Canon of Medicine" by Arman Zargaran, Afshin Borhani-Haghighi, Pouya Faridi, Saeid Daneshamouz, and Abdolali Mohagheghzadeh
In this article, the researchers highlight the major contributions ibn Sina made to the study of migraine or shaqhiqheh. They point out that most of his pathologies of migraine are supported by current concepts of medicine and that the medicinal plants he prescribed for its treatment do have properties which can help alleviate migraine symptoms.
"History of headache in medieval Persian medicine" by Ali Gorji and Maryam Khaleghi Ghadiri
Like the previous article, this one looks at the sophistication of treatment and understanding of headache disorders among medieval Persian doctors. It was incredible for me to see that over a thousand years ago, these doctors recognised that migraine is not just a headache: they connected it to the other symptoms we know today like nausea, visual hallucination, tinnitus, aphasia, vertigo, abnormal pulse, drowsiness, memory issues, and tremors. They knew that migraines could be triggered by exercise and changes in the menstrual cycle or the weather, and that they could be co-morbid with anxiety and depression. Considering how often my own doctors in the past have dismissed some of these aspects, it's incredible to see how advanced Persian scientists were so long ago. Modern Iranian doctors continue to research and treat migraine today - you can learn more about it on the website of the Iranian Headache Association.
"Women Mystics in Medieval Islam: Practice and Transmission" by Jean-Jacques Thibon
An overview of the importance of women in the development of Islamic mysticism. Thibon gives several examples of early Sufi women from Nishapur and says how in the 10th century, "the great metropolis of Nishapur offered an environment which enabled women to participate actively in the spiritual life of the city, at least for those belonging to a certain elite". You can read about these women in more detail in Early Sufi Women by Abū 'Abd ar-Rahmān ās-Sulamī, edited and translated by Rkia Elaroui Cornell.
Nishapur: Some Early Islamic Buildings and Their Decoration by Charles Kyrie Wilkinson
I chose Nishapur for the setting of my illustration because I was able to track down this archaeological report about the excavation of a bathhouse from the 10th century. There are lots of cool details here about some of the objects and art found in the bathhouse. Other treatments of the magnificent art of Nishapur include "Animal, Vegetal, and Mineral: Ambiguity and Efficacy in the Nishapur Wall Paintings" by Finbarr B. Flood; "Early Islamic pigments at Nishapur, north-eastern Iran: studies on the painted fragments preserved at The Metropolitan Museum of Art" by Parviz Holakooei, Jean-François de Lapérouse, Martina Rugiadi, and Federica Carò; and "Feasts of Nishapur: Cultural Resonances of Tenth-Century Ceramic Production in Khurasan" by Oya Pancaroğlu. For an overview about the history of the city, check out "Why Nishapur?" by Richard W. Bulliet.
"Facts and Figures" on The Migraine Trust
This UK-based website provides a great rundown of the important facts and figures about migraine disease today. In the US, you can learn more about National Migraine and Headache Awareness Month here.
"A review on the management of migraine in the Avicenna's Canon of Medicine" by Arman Zargaran, Afshin Borhani-Haghighi, Pouya Faridi, Saeid Daneshamouz, and Abdolali Mohagheghzadeh
In this article, the researchers highlight the major contributions ibn Sina made to the study of migraine or shaqhiqheh. They point out that most of his pathologies of migraine are supported by current concepts of medicine and that the medicinal plants he prescribed for its treatment do have properties which can help alleviate migraine symptoms.
"History of headache in medieval Persian medicine" by Ali Gorji and Maryam Khaleghi Ghadiri
Like the previous article, this one looks at the sophistication of treatment and understanding of headache disorders among medieval Persian doctors. It was incredible for me to see that over a thousand years ago, these doctors recognised that migraine is not just a headache: they connected it to the other symptoms we know today like nausea, visual hallucination, tinnitus, aphasia, vertigo, abnormal pulse, drowsiness, memory issues, and tremors. They knew that migraines could be triggered by exercise and changes in the menstrual cycle or the weather, and that they could be co-morbid with anxiety and depression. Considering how often my own doctors in the past have dismissed some of these aspects, it's incredible to see how advanced Persian scientists were so long ago. Modern Iranian doctors continue to research and treat migraine today - you can learn more about it on the website of the Iranian Headache Association.
"Women Mystics in Medieval Islam: Practice and Transmission" by Jean-Jacques Thibon
An overview of the importance of women in the development of Islamic mysticism. Thibon gives several examples of early Sufi women from Nishapur and says how in the 10th century, "the great metropolis of Nishapur offered an environment which enabled women to participate actively in the spiritual life of the city, at least for those belonging to a certain elite". You can read about these women in more detail in Early Sufi Women by Abū 'Abd ar-Rahmān ās-Sulamī, edited and translated by Rkia Elaroui Cornell.
Nishapur: Some Early Islamic Buildings and Their Decoration by Charles Kyrie Wilkinson
I chose Nishapur for the setting of my illustration because I was able to track down this archaeological report about the excavation of a bathhouse from the 10th century. There are lots of cool details here about some of the objects and art found in the bathhouse. Other treatments of the magnificent art of Nishapur include "Animal, Vegetal, and Mineral: Ambiguity and Efficacy in the Nishapur Wall Paintings" by Finbarr B. Flood; "Early Islamic pigments at Nishapur, north-eastern Iran: studies on the painted fragments preserved at The Metropolitan Museum of Art" by Parviz Holakooei, Jean-François de Lapérouse, Martina Rugiadi, and Federica Carò; and "Feasts of Nishapur: Cultural Resonances of Tenth-Century Ceramic Production in Khurasan" by Oya Pancaroğlu. For an overview about the history of the city, check out "Why Nishapur?" by Richard W. Bulliet.
"Facts and Figures" on The Migraine Trust
This UK-based website provides a great rundown of the important facts and figures about migraine disease today. In the US, you can learn more about National Migraine and Headache Awareness Month here.