Cephalalgia

The first descriptions of migraine can be traced back nearly 4,000 years from the ancient civilizations of Mesopotamia (Sumeria and Babylonia) through Egyptian, Greek and Roman epochs. Through Byzantine, Arabic and Medieval times there are only patchy references until the 17th century, when European physicians first gave full case reports.

The copyrights of this document belong to the International Headache Society Committee on Clinical Trials in Migraine. This document is not copyrighted in the English version provided the source is acknowledged. Translations to other languages must be authorized by a national headache society associated with the International Headache Society.

Dysfunction of the descending circuitry that modulates nociceptive processing is thought to facilitate primary headache disorders such as migraine and cluster headache, either by reducing inhibition or increasing facilitation of neural signals. The identification of novel neurotransmitter systems (orexinergic, cannabinoid and dopaminergic) within this descending pathway and their interaction with 5-HT_1B/1D (triptan) receptors provides important clues about several of the risk factors and comorbidities associated with primary headache disorders and indicates that triptans exert central as well as peripheral activity. Current research supports the early treatment of primary headache disorders in order to prevent structural changes in the brain and to minimize dysfunction in the descending modulation of pain control.

It is important that physicians practise evidence-based medicine. Clinical experience is important, but there are a number of reasons why clinical experience can lead to the impression that ineffective treatments are effective. There are major educational and research challenges which must be met before clinicians can practice evidence-based migraine therapy more extensively than at present. Treating physicians will need to learn more about the principles of evidence-based medicine. Researchers will need to produce more and better clinical trials that address important clinical questions. The results of these trials will need to be reported clearly, and we need to improve the efficiency with which these results can be accessed. It is important that the pharmaceutical industry, clinicians, and academic health centres work together to meet these challenges.

EEG-studies in migraine in the last decade has contributed modestly to the understanding of headache pathogenesis. Headache patient groups seem to have increased EEG responses to photic stimulation, but a useful biological marker for migraine in single patients has not been found. In future EEG and QEEG studies we recommend to use follow-up designs and record several EEGs across the migraine cycle. It is also important to use a blinded study design in order to avoid selection bias.

A clinical EEG should be performed in patients with acute headache attacks when either epilepsy, basilar migraine, migraine with prolonged aura or alternating hemiplegia is suspected. Unequivocal epileptiform abnormalities usually suggest a diagnosis of epilepsy. In children with occipital spike-wave activity the probable diagnosis is childhood epilepsy with occipital paroxysms (CEOP). The final diagnosis of either an epilepsy syndrome or migraine must be mainly based on a clinical judgement.

General practitioners (GPs) play a pivotal role in managing migraine and ensuring that patients have a positive first experience when seeking treatment. A large proportion of migraineurs do not consult a GP, preferring to rely on over-the-counter remedies to reduce pain and disability. For those who do consult, receiving a satisfactory outcome at their first consultation is important for ensuring subsequent effective management of their migraine. If patient expectations are not met at their first visit (prescribed treatment is ineffective or GP does not empathize with their suffering), patients may not return for further consultation. There remains a need to improve migraine diagnosis and treatment, and GPs require continuing medical education and neurologist support to ensure that they are providing the best migraine treatments and outcomes. More widespread use of diagnostic tools, standardized management guidelines and individualized treatment regimens will help GPs successfully manage both migraine symptoms and patient expectations.