14ournalofNeurologyNeurosurgeryandPsychiatry199457134143NEUROLOGI - PDF document

14ournalofNeurology,Neurosurgery,andPsychiatry1994;57:134-143NEUROLOGICALMANAGEMENTHeadacheJMSPearceCurrentissues:generalmanagementMORBIDITY:THEBURDENOFHEADACHETOPATIENTANDSOCIETYMorbidityduetoheadachesisamajorprob-lem.Tensionheadachesoutnumbermigraineby5:1.Table1comparesthemorecommoncausesofchronicorrecurrentheadachesindifferentagegroups.ArecentstudyfromMinnesota,UnitedStates,confirmstheoverallincidenceofmigrainetobeabout10%inthepopulation,withamarkedvariationrelatedtoageandahigherincidenceinwomeninadefinedpopu-lation.'From6400patientrecords,629resi-dentsfulfilledtheInternationalHeadacheSociety's(IHS)1988criteria2formigrainebetween1979and1981.Theoverallage-adjustedincidencewas137and294per100000personyearsformalesandfemalesrespectively.Thehighestincidencewasinwomenaged20-24years(689per100000personyears),whereasinboysaged10-14years,theincidencewas246per100000personyears.Basedonastudyof1000peopleusingtheInternationalHeadacheSociety'scriteria,theoveralllifetimeprevalenceofclassicmigrainewas5%,withafemaletomaleratioof2:1.3Theoveralllifetimeprevalenceofcommonmigrainewas8%,withafemaletomaleratioof7:1.Womenweremorelikelytohavecom-monthanclassicmigraine.Neitherclassicnorcommonvarietiescorrelatedwithage,butinbothtypesthemostconspicuousprecipitatingfactorwasstressandmentaltension.Therateofconsultationisaconcernforthoseplanningmedicalresources.Amongsubjectswithclassicandcommonmigraine,50%and62%,respectively,consulttheirgeneralpractitionerbecauseofmigraineatTable1Commonheadachesatdifferentages3-16(years)17-60(years)60+(years)MigraineMigraineReferredfromneckTensionheadacheTensionheadacheCranialarteritisPsychogenic/fatigueClusterheadachePaget'sdiseaseoftheskullPost-traumaticPost-traumaticGlaucomaOccasionallyCranialandduraltumoursCranialandduraltumours.Tumours:posteriorfossa,intraventricularCerebraltumoursincludingCerebraltumoursincludingabscessandsubduralabscessandsubduralhaematomahaematomaDepressionRareclusterheadacheReferredfromneckPaget'sdiseaseoftheskullPaget'sdiseaseoftheskullPost-herpeticandcranialneuralgiasPost-herpeticandcranialPost-traumaticneuralgias*ContinuingtensionheadacheContinuingmigraine*Uncommonpresentationatthisage.sometimeintheirlives.Patientsfrequentlyattendformedicalhelp,andlosemuchtimefromworkwhichisoftenunrecorded.Inarandomsampleof740subjects,aged25-64yearslivingintheCopenhagenCounty,Denmark,119hadmigraineand578hadtensionheadache(1:5).4Amongsubjectswithmigraine56%hadconsultedtheirgeneralpractitionerinthepreviousyearformigraine;amongsubjectswithtensionheadache16%hadhadconsultations.Specialistshadbeenconsultedby16%ofmigrainesufferersandby4%ofsubjectswithtension-typehead-ache.Lessthan3%ofallpatientsstudiedhadrequiredhospitaladmissionandlaboratoryinvestigationsforheadache.Halfthemigrainesufferersand83%ofsubjectswithtension-typeheadacheinthepreviousyearhadtakendrugtherapy.Thusmigraineandtensionheadachescanbeseenaspotentsourcesofdemandformedicalattentionandfortheconsumptionofdrugs.IntheDanishstudy,43%ofemployedmigrainesufferersand12%ofemployedsub-jectswithtension-typeheadachehadlostworkingtimeintheprecedingyear.Thetotallossofworkdaysduetomigrainewasesti-matedat270per1000personsperyear;fortensionheadachethecorrespondingfigurewas820.Womenconsultadoctormoreoftenthanmen,butthereisnosexdifferenceinabsenteeism.PRINCIPLEOBJECTIVESANDINSTRUMENTSOFMANAGEMENTIfapatientwithheadachehascranialarteritisorabraintumour,thenallsociologicalinter-ventionmusttakesecondplacetopromptdiagnosisandtreatment.Over95%ofpatientsseeninageneralpractitioner'ssurgeryorhospitalclinic,however,haveten-sionheadache,migraine,oratypicalheadachewithoutastructurallesion.Forsuchpatientswhosesymptomsarestronglyinfluencedbysocial,personal,andfamilyproblems,severaltherapeuticcommoditiesareneeded.Foreffectivetherapydoctorsneedtobeaccurateindiagnosis,clearinthedirectionoftreatment,honestwhentheydonotknowhoworwhyasymptomhasdevelopedorchanged-yetreassuring.Theyshouldbeunderstandingbutnotdismissive;andtheyshouldbepreparedtoseepatientsrepeatedlyuntiltheheadachesarecontrolled,andespe-ciallytocontinuetocomfortandsupportwhentheyarenotcured.Suchparagonsarenotubiquitous.Painstakingeffortstocom-municatewithpatientsfromthestartsavemanysubsequentconsultations.304BeverleyRoad,Anlaby,HullHU107BG,UKJMSPearceCorrespondenceto:DrPearce134 HeadachePoliticalandfinancialconstraintshavefailedtoprovideforthenecessarynumberofdoctorhourstocaterforthisideal.Inreality,thishasbeenmatchedbythenever-endingexpectationsofpatientsforthelatesttechnicalfacilities,foraspecialist'spersonalattentions(nolongerisaconsultantorevenaneurologistadequate;ithastobea"headacheexpert"),and

forclinicalinfallibil-ity-orelse,litigationmayresult.Suchissuesoftimeandexpertisehave,bydefault,producedthenotionthatnurses,socialworkers,osteopaths,homeopaths,andpsychologists,amongothers,mightprovideforthesepatients.Regrettably,theycannot.Although,undermedicaldirection,theycanhelp,theyarenosubstituteforadoctor'strainingandknowledge.Physiciansareunwisetoabrogatetheirtraditionalrolebydelegatingpatients'managementtoletthem-selvesoffthehook.Suchfashionabletrendsdenigratethephysicians'role,butmuchmoreimportantly,diminishtheirtherapeuticeffec-tiveness.Thearmamentariumis,however,limited.Thefrustrationofimplacablepatientsisreflectedintheirsearchfor"alternativethera-pies".Medicalscienceassessesitstoolsbyrigorousanalysisandscientifictrials.Medicineshouldnotbedauntedbypracti-tionersofalternativemedicinesince,withrareexceptions,theyhavesofarfailedtosub-jecttheirunboundedclaimsoftherapeutictriumphstoscientificscrutiny.Whentheydoso,andwhentheirmethodsproducevali-datedbenefit,physiciansshouldwelcomeandusethem.Generalpractitionersprovideprimarydiag-nosticfacilitieswhichessentiallyservetosep-aratethosewithmajorpathology(tumours,glaucoma,arteritis)fromfunctionalhead-aches.Manyofthelattergrouparedealtwithadequatelybyhistorytaking,examination,reassurance,andselectedanalgesicsandantimigrainedrugs.Patientsposingdiagnos-ticproblemsandthosewithrefractoryhead-achesshouldbereferredtoaneurologist."Headacheclinics"areconvenient,andwellsuitedtotrialsandresearch;but,tobeofbenefittopatientstheyshould,ideally,beavailableonadailybasis,staffedbyoneormoreexperiencedphysicianstoprovideconti-nuityofservice:theseidealsarenotgenerallypracticable.AuditThisconcept,woollyindefinitionandofteninadequateinapplication,isnoteasytoimposeonthemanagementofpatientswithheadaches.Patientsandtheirgeneralpracti-tionerscanbequestionedabouttheirsatis-factionwiththeservice;improvementinheadachescoreswouldneedseveralapplica-tionsperpatientoveralongperiodoftimetodemonstrateefficacyabovethesubstantialplaceboeffectofseeinganewdoctor,receiv-ingtheinvestigationsthatpatientsperceiveasreassuring,andbeingofferednewtreatments.Withoutimplementationofresultsofaudit("closingtheloop")andfurtherappraisal,theexerciseismeaningless.Toinstigatestan-dardsofgoodpractice,yardsticksneedtobeestablishedandagreed.Inadistrictorregionalservice,theassess-mentofwrongdiagnoses-forexample,missedtumours,subarachnoidhaemorrhage,ormissedcranialarteritis,isfeasible.Similarlyerrorsofdiagnosis,choiceoffirst-linetreatmentandpatternsofsecondaryreferralcanbeappraisedincasualtydepart-mentsandingeneralpractitionerreferrals.TheheadachepatientThisaccountisrestrictedtoheadacheandexcludestherelatedbutseparatefacialpainsandneuralgias.Theclinicalapproachrestsheavilyonadetailedanalysisofsymptomsandathoroughgeneralandneurologicalexamination.Selectiveinvestigationsareapplicabletoonlyasmallnumberofpatientswhorequireneurologicalreferral(table2).Headachesmaybeacute,usuallysignifyingmeningealirritationor,rarely,raisedintracra-nialpressure(ICP),recurrentasinmigraine,orchronicasintensionheadaches.HEADACHEASASYMPTOMOFINTRACRANIALDISEASEFewheadachesfailtoevokesomeanxiety,whichcandistort,disguise,ormagnifytheprimaryclinicalfeatures.Confrontedbyapatientwithheadaches,thefirstclinicalresponsibilityistoexcludeastructuralordynamiccause.Anyexpandingmass-tumour,abscess,orhaematoma-cancauseraisedpressure.Headachesofabruptonsetmaysignifytrauma,spontaneousintracranialhaemor-rhage,hydrocephalus,oracutemeningealirritationatanyage;theelderlyarenotimmune.Themostcommoncauseisacutemeningealirritationduetosubarachnoidhaemorrhageortomeningitis-bacterialorviral,(rarelyHIV,fungal,ormalignant).Anabruptonset,fever,neckstiffness,andKernig'ssignaccompanytheobviousseverepain,vomiting,andphotophobia.HospitalreferralforCSFexaminationismandatoryifhaemorrhageorinfectionisconsidered.CT(orMRI)shouldbethefirstinvestigationtoexcludeamasslesion,haematoma,orhydro-cephalus,eachofwhichcontraindicateslum-barpuncture.Subarachnoidhaemorrhagemaybeshown,butcanbemissedbyCTinupto20%ofpatientsonadmission.Whenamasslesionisexcluded,lumbarpuncturemaybenecessarytoexaminetheTable2Indicationsforspecialistreferralandinvestigations*Suddenonset,newheadache*Atypicalsymptomsorsignssuggestingorganicpathology*Abnormalsigns-forexample,papilloedematosuggestraisedintracranialpressure;ared,tenderscalpvesseltoindicatecranialarteritis*Anunremittingcourse,unresponsivetoconventionaltreatment*Theadventofprogressivephysicalsigns135 PearceCSFforsubarachnoidbleedingandmenin-gitis.Acutemigraineandtensionheadacheuncommonlyproduceameningiticpicture,diagnosableonlybyexclusion.Acutehead

acheshouldbedistinguishedfromthecommonandtotallybenign"explodingheadsyndrome"inwhichpatientsarealarmedbyasudden,momentary,veryloudnoiseinthetwilightstageofsleep.5Raised-pressureheadacheThisisanaching,throbbingheadacheaggra-vatedbyalcohol,exertion,andbycoughingorstraining.Thesefeaturessuggestavascularorhydrodynamicmechanismwhichmaybecausedbyatumourorhydrocephalus.Similarsymptoms,however,arealsocom-moninmigraineandothervascularpains.Thelocationisnon-specific,althoughwhenaprogressiveheadacheradiatestotheneck,tonsillarconingisimminent.Theheadacheis:(a)worseinthemorningandmaywakenthepatientfromsleep;(b)aggravatedbysit-tinguporstandingandrelievedbylyingdown;(c)aggravatedbycoughing,straining,andvomiting;(d)relievedbyaspirinorparac-etamolintheearlystages(incontrasttopsychogenicheadache);(e)associatedwithvomitingandeventuallybypapilloedemaandprogressingfocalsigns.Bythestageofstuporandhemiplegiawithadilated(Hutchinson's)pupil,diagnosishasbeendelayedtoolong.ChronicandrecurrentheadachesREFERREDPAINTheorbits,paranasalsinuses,cervicalspine,mediastinum,andteethcancausepainreferredviabranchesofthetrigeminalnervetotheforeheadandtemple.Sinusitisandtoothachearecommonplaceexamples,butotitismedia,glaucoma,orbitalcellulitis,andcavernoussinusthrombosismayproducereferredfrontotemporalpain.Secondaryinvoluntarycontractionofscalpandfacialmusclesfurthercomplicatethepicture,caus-ingasecondarygeneralised"tensionhead-ache"whichmayobscuretheprimarysource.Primarycarephysicianscantreatacuteinfec-tionbyantibioticsbut,whencranialspreadissuspected,patientsshouldbeimmediatelyreferredtotheneurological/neurosurgicalcentre.TENSIONHEADACHETensionheadacheisthemostcommonofhumancomplaints,constituting70%ofrefer-ralstoa"headacheclinic".Itisoftenashort-livedcomplaintwithanobviousprecedingcause:overwork,lackofsleep,oranemo-tionalcrisis.Thisisbenignandoftendesig-natedbypatientsas"mynormalheadaches".Currentsystemsclassifythemostcommonrecurringheadachesaseithermigraineorten-siontype.Thistraditionalapproachcanbequestioned.Somesuggestthatthesetwoheadachepatternsarebutdifferentexpres-sionsofthesamepathophysiologicalprocess,havingoverlappingsymptomaticpresenta-tionswithcertainfeaturesemphasisedtoagreaterorlesserextent.Additionally,thesametherapieshavebeenshowntobeeffec-tiveforpatientsineitherheadachegroup.6Analternativecontinuumclassificationmodelhasbeensuggested,asthereisanundoubtedoverlapbetweencommonmigraineandten-sionheadache,althoughtheircommonco-existencehasaddedtotheconfusion.Bycontrast,SolomonandLiptonproposethatthediagnosisofmigrainewithoutaura(commonmigraine)iswarrantedifanytwoofthefollowingsymptomsarepresent:unilat-eralsite,throbbingquality,nausea,photo-phobia,orphonophobia.7Thesecriteriaarederivedfromastudycomparingthefeaturesof100patientswithmigrainewithoutauraand100patientswithchronicdaily("ten-sion")headache.Theauthors'proposedcri-teriaforthediagnosisofmigrainewithoutaurawerehighlysensitiveandadequatelyspecificindiscriminatingthetwogroups.Therearealsodifferencesinlaboratorydata.Bindingof3H-labelledimipraminetoplateletswasmeasuredandasignificantreductionwasfoundinmigrainecomparedwithcontrolsbutnotintensionheadache.Inmigraine,therewasnosignificantrelationshipbetweenimipraminebindinganddepressionoranxietyscoresuggestingthatthereductioninplateletimipraminebindingisaconcomi-tantofmigraineitself.8Asignificantreduc-tioninperipheralbloodmononuclearcellfl-endorphinconcentrationswasobservedinmigrainepatientswithandwithoutaura,butnotinpatientswithtension-typeheadache.9Adultandchildhoodmigraineurswithoutaurahaveanincreasedamplitudeofthecon-tingentnegativevariationbetweenattacks.'0Likewisevascularphenomena,welldescribedinmigraine,contrastwithtranscranialDopplerultrasoundofbloodflowvelocitiesinchronictensionheadachewhichshownosignificantdifferencesfromcontrols.Thecaseforclassicmigraineasaseparateentityisevenmorepersuasive.Theteenagerwithinfrequentbutprostratingattacksofphoto-psiae,dysphasia,vomiting,andhemicrania,isatleastclinicallydistinctfromtheangst-ridden40-year-oldpatientwithcontinuous,daily,vertex,pressureheadachefor20yearswhichdoesnotpreventremunerativework.AcutetensionheadacheThistypeofheadacherarelypresentsasanemergency.Whenitdoes,theheadachehasincreasedoverafewhours,buthasbecomeverysevere,simulatingsubarachnoidbleed-ing.Lumbarpuncturemaybenecessarytoexcludemeningealirritationbybloodorinfection.Moreoftentheemotionalbasisisobviousandrecoveryensuesquicklyafterreassurance,analgesia,andsedation.Liaisonwiththegeneralpractitionershouldleadtocontinuedsupportandpromptreturntowork.Chronictensionheadache(chronicdailyheadache)Morecommonthantheacutesyndr

ome,painisdiffuselyfeltalloverthehead,oftenlocated136 Headacheonthevertex,ormaystartintheforeheadorintheneck.Primarytensionheadacheispsy-chogenic;itsmechanismsarenotwhollyunderstood.'1Itiscommonlybilateral,butmaybeunilateral.Patientscharacteristicallycomplainofpressure,afeelingoftightness,oraheavyweightpressingonthecrown."Atightbandlikeaskullcap"or"asifaclamporvicewassqueezingmyhead"arecommondescriptions.Manysay"itisnotreallyapain,butapressure".Thesymptomsmayalsoseemtoderivefrominsidethecranium:"asifmyheadisbursting"or"abouttoexplode".A"creeping"sensation(formication)maybefeltunderthescalp,orasenseofsharpknivesorburninghotneedlesdrivenin,mayberelated.Tensionheadacheoccursdaily,worseintheevenings.Visualdisturbance,photopho-bia,andvomitingseldomoccur.Mostpatientscontinuetheirnormalwork.Symptomscontinueforyearswithoutevidentdeteriorationofgeneralhealth.Symptomsareworsewhenthepatientistiredorunderpres-sureofwork,ordomesticstresses.'2Mostsuf-ferershaveinsight,sothatacarefullytakenhistoryclarifiesboththediagnosisandtheaggravatingcircumstances;manyareemo-tionalandanxiouswithfearsofbraintumours,hypertensionor'clotsinthebrain'.Ienquirespecificallyaboutfearsofseriousbraindisease,whetherthefearsarevoicedbythepatientornot.Illnessesseenontelevisionprogrammes,likemaladiesofrelativesandacquaintances,areoften"contagious";thesetooneedcarefulappraisal.Thoroughclinicalexaminationisoftheutmosttherapeuticvalueandprovidesarationalbasisforeffec-tivereassurancethatisdeniedtothepsychol-ogistorcounsellor.Treatmentismosteffectivewhenthehis-toryisshort.Tocuresuchheadachesaftermanyyearsisadauntingandoftenunsuc-cessfultask.'3Animportantstepistoenquireabouttheeventsthatdeterminedtheonset.Theseareoftenforgotten,orperhapssup-pressed,yetrepeatedenquiryatsubsequentconsultationswilloftenunraveltheapparentmystery,theconsequentknowledgebeingsufficienttoexplainthecausetothepatient.Sensitivepatientswithfragilepersonalitiesmaybeunabletocopewithlife'sstressesandunconsciouslyuseheadachestoescaperesponsibilitieswithwhichtheycan'tcope.Sedatives,tranquilizers,andtension-relievingdrugsareoflimitedvalueunlessthepsycho-logicalissuesareadequatelyhandled.Glibreassurancewillnoteradicateheadacheiffundamentalpsychologicalproblemsareunresolved.Whenthehistoryisshortandifacauseisexposed,explanationandreassurancemaysuffice.Patientsoftenabuseanalgesicswhichaggravatethesituation,buttheabuse,withpersuasion,canbereversedwithdramaticbenefit(seebelow).Moreoften,whendailypainhaspersistedforyears,theprognosisispoor,butshortcoursesofbenzodiazepinesoramitriptylinemaybehelpful.Supportivepsy-chotherapyinliaisonwithapracticenurseorpsychotherapistmayhelp:muchdependsonthequality,experience,andgoodsenseoftheindividualavailable.Latentdepressionpresentingastensionheadacheiseasilyoverlooked.Earlymorninginsomnia,negativism,anhedonia,guilt,anddiurnalmoodswingsaresuggestive.Theheadacheisworseinthemorning(resemblingthatofraisedpressure),andacauseforthemiseryisnotalwaysapparent.Fulldosesoftricyclicantidepressantsorfluoxetineareneeded.46Theprognosisfordepressionisoftengood.MIGRAiNEClassicmigraineClassicmigraineissynonymouswithmigrainewithauraandoccursin20%ofpatients.Itisaparoxysmaldisorderwithheadaches,oftenunilateralattheonset,asso-ciatedwithnausea,anorexia,andoftenvom-iting;itisprecededoraccompaniedbyvisual,sensory,motor,andmooddisturbancesandisoftenfamilial.CommonmigraineThisissynonymouswithmigrainewithoutauraandoccursin75%ofpatients.Thetermreferstosimilarparoxysmalheadacheswith-outtheaura.Bothtypesofattackmayoccuratvarioustimesinthesamepatient.Itiscommonformigraineurstohavetensionheadachesbetweentheirmigraines:theseshouldbeidentifiedtopreventmisdirectedtreatment.Dailyheadachesarenevermigrainous.MigrainevariantsThesearehemiplegic,basilar,andophthal-moplegic,migrainesinecephalgia,etc,andoccurinlessthan5%ofpatients,usuallyrequiringaneurologist'sappraisalandsome-timesbrainimaging.NaturalhistoryandmanagementInchildhood,attacksbeginbeforetheageof10yearsinathirdofpatients.Theymaybeoverlookedifthechildisunabletodescribeheadachesandstrangevisualorsensoryexpe-riencesclearly.Theyarealsoconcealedbylabelsof"biliousattacks"or"periodicsyn-drome".Diagnosiscanbedifficultasaffectedchildrenmaysimplyappearpale,ill,limp,andinert,complainingofpoorlylocalisedabdominalpain.Headacheisusuallypresent,vomitingiscommon,andtheremaybeafeverofupto38-5°Csothatthesuspicionofappendicitisormesentericadenitisoftenarises.Itshouldberememberedthatover80%ofmigraineurshavetheirfirstattacksbeforetheageof30years,andthediagnosisshouldthereforebeviewedwithsuspicionifonsetisaftertheageof40,althoughanincreasedfrequencyofat

tacksatthemenopauseiscommon.Somesubjectshaveonlyafewattacksinalifetimebutmosthaveseveralattackseachyear.Promisesofremis-sionatthemenopauseareoftenill-founded,thoughattackstendtolessenaftertheageof50years.Remissionoccursin70%of137 Pearcepregnancies.Itiswellrecognisedthatexacer-bation,orcomplicatedmigrainewithinfarc-tion,mayresultfromoestrogen-containingcontraceptives.'4Manyattacksinadultsendgraduallyafter24to48hoursbutattacksinchildrenoftenlastonlytwotosixhours.Inlaterlifehead-achesmaydisappearcompletely,attackspre-sentingwithteichopsiaeandnoheadache(migrainesinecephalgia).Themechanismisuncertain.Indeed,theapparentonsetofmigraineintheelderlyimpliesatheroscle-rotic,thromboembolicdisease.Foodidiosyn-crasies,foodallergies,redwines,specificdietaryamines,andomissionoffoodareoccasionalprecipitants.Emotionalstressandfatigueistheprincipalaggravatingfactorbutisnotcausal.Migraineisdeterminedbyaprimarilycere-bral(neural)mechanismwithafluctuatingthresholdwhichdeterminesthetimingandpatternofattacks.'5Aneuraltriggeractivatesthetrigeminovascularreflex,releasingvaso-genicaminesfrombloodvesselwallsaccom-paniedbytheirpainful,pulsatiledistension.Thecerebralmechanismrespondstomood,emotions,tiredness,relaxation,hormonalchanges,andtobrightlights,andnoise.Itsthresholdissusceptibletohypothalamicfunc-tionwhich,intum,ismodulatedbyseasonalpattems,diurnalandbiologicalclocks,andbyhormonalfactorsandcoitus.'6Personalityandvariationsofmoodandbehaviouralsoinfluencethepattemofattacks,remissions,andtreatment.SYMPTOMATICTREATMENTAssessmentofthepatient'shabits,work,per-sonality,andstressesisimportant.Suitablytrainedclinicnursescanassistinthetime-consumingelucidationofthesefactorsinselectedcases.Knownprecipitantsshouldbesought,withtheaidofadiaryandshould,whenpossible,beeliminated(table3).Thepatient'srecognitionofstressfulpattemsandtheacceptanceofabenigndisorderwillachievesomebenefit.Goodrapportenhancesreassuranceandfacilitatesthemarkedplaceboeffectofalltherapywhichoftencon-foundstheanalysisofdrugtrials.Theaimsoftreatmentarethecontrolofsymptoms,andthepreventionorreductionofattacks.Manyprophylacticdrugsactbycen-tralserotonin(5HT,)antagonism,'7whereascontrolofanattackreliesonconstrictionofcranialvesselsmediatedbya-adrenergicor5HT,receptors.'8Table3Commonprecipitantsofmigraine*Fatigue,overwork,travel*Relaxationafterstress-holidayandSaturdaymorningheadache*Brightlights,discos*Sleepexcessorshortage-Sundaymorningheadache*Missingmeals*Raredietarysensitivity*Alcohol,redwines*Menstruation*Exercise-relatedvascularheadaches:footballer'smigraine,coitalcephalgiaAnalgesicsRest,dark,andquiet,wherepracticable,aresupplementedbysimpleanalgesics(paraceta-mol1gorsolubleaspirin06g)ornon-steroidalanti-inflammatorydrugssuchasnaproxen500mg.Theadditionofcaffeineandspasmolyticsaddtoexpensebutnottobenefit.Codeine15-30mgmayenhancepainrelief.Analgesicsshouldbetakenimmedi-atelytheattackbegins,thenrepeatedfourtosixhourlyasneeded.Absorptionisimprovedbyingestionwithmetoclopramide10mgordomperidone10-20mg.Ifvomitingissevere,suppositoriesofdomperidone,prochlorper-azine,orchlorpromazinearevaluable.Analgesicabusecancauseheadaches.ErgotamineErgotamine(ordihydroergotamine'9)isaneffectiveremedyforacuteattacksinabout50%ofcasesandshouldbetriedbeforemoreexpensiveagents.Ergotaminehasnoplaceasaprophylactic,however,and,whenoverused,canleadtohabituationwithergotamine-dependentheadache,similartochronicanal-gesic-dependentheadacheswhichmimicmigrainestatus.Whensuspected,thedrugsshouldbewithdrawn,ofteninhospitalundershort-termsedation.Ergotamineisana-adrenergicagonistwithpotent5HT1receptoraffinity,apotentvasoconstrictor.Absorptioniserratic,oraldosesoftenproducingsub-therapeuticbloodlevels.Suppositories(1-2mg),inhalation(0-36mg),orsublingual(1-2mg)arethemosteffectiveacceptableroutes,butinjec-tionsarenotgenerallytolerated.Iftwodosesatintervalsoftwotosixhoursareineffective,nomoreshouldbegivenforthatattack.Ifapatientistakingergotaminemorethantwiceeachweek,thereisamajorriskofhabituation.Manypatientsexperiencevaguemalaise,nausea,andcrampswithergotamine,butcoronary,cerebral,andlimb(StAnthony'sfire)ischaemiaarerare,butwell-proven,hazards.Vascularclaudi-cation,angina,andpregnancyarecontra-indications.SumamiptanThisisaspecificandselectiveagonistof5HT1receptorsoncranialbloodvesselscaus-ingvasoconstriction.YIthasnegligibleeffectsonotherreceptors.Sumatriptandoesnotpenetratetheblood-brainbarrierandhasnoCNSeffects.Intravenoussumatriptandoesnotchangeregionalcerebralbloodflow;itconstrictsthecarotidvascularbed,buthasnoeffectonpialvesselsincats.Ithasaplasmahalf-lifeoftwohours.Thesubcutaneouspreparation(6mg)

givesreliefofheadachein77%patientsat60minutes,andin83%attwohourswithcorre-spondingimprovementinnausea,vomiting,andphotophobia.2'Inclusterheadachetoo,itiseffectivewithreliefofsymptomsat15min-utesin74%comparedwith26%givenplacebo.22Oralmedication(100mg)providesreliefinabout70%ofattackswithintwohours.23138 HeadacheSecondandthirdattacksrespondaswellasthefirst.Comparativetrialshaveshownslightbutsignificantsuperioritytoaspirin900mgplusmetoclopramide10mg.Recurrenceofheadacheoccurswithin48hoursin42%ofpatients.24IncomparisonsofsumatriptanandCafergot,oralsumatriptan100mgrelievedheadacheaftertwohoursin66%comparedwith48%ofthosegivenoralCafergot.2'Thepoororalabsorptionofergotamine,however,wasaseriouslimitationofthisstudy.Anotherstudyshowedagoodresponsetooralsumatriptanin51%ofpatientsattwohourscomparedwith9%givenplacebo;res-cuemedicationwasneededin41%ofthesumatriptangroup,butin88%oftheplacebogroup.26Atotalof39%,however,hadrecur-rentheadachewithin24hours-asignificant"reboundeffect"whichmayrelatetothenat-uralhistoryofmigraine,ortoapharmacolog-icaleffect.Inover100000treatedattacks,toxicityhasnotbeenaproblem.27Therearenowprovencardiovascularischaemicsequelaewithangina,infarction28andventriculararrhythmias,butthesearerareifestablishedischaemicheartdisease,prinzmetalangina,andarrhythmiasarerespectedascontraindi-cations.Vaguenon-ischaemicchestdiscom-fortoccursinsomepatients.Nausea,vomiting,andtingling,deemedmildandtransient,occurin38%patientswithinfourhours.Reboundinathirdofpatientsrespondswelltofurtherdoses,butcom-poundsthepressingissueofcost.Sumatriptanisaneffective,safe,andpromptremedy,suppressingallthesymptoms,notheadachealone.29Itworksin70%ofsuffer-ers,however-notineverypatient.Thepresenthighcostlimitsitsuse.Goodcommunicationwithfamilydoctors,advicebyclinicorpracticenursesontheuseofself-injectorsandinhalersandthefre-quencyoftabletsareimportant.Auditoftheresultsoftreatmentbycompletingheadachechartscanbeinvaluable,butpatientsshouldnotoverusediarycardswhichcanengenderexcessiveintrospectionandneurosis.PROPHYIAXISProphylaxisshouldbeconsideredifattacksoccurmoreoftenthantwiceeachmonth.Non-pharmacologicaltechniquesaresuccess-fulincertainsubjects,butclaimsfortheirgeneralapplicationshouldbeviewedwithscepticism.Currentdatasupportnosignifi-cantdifferenceintheefficacyofhypnosis,biofeedback,andrelaxationtraining.Prophylacticsaimtoreducethefrequency,butnoneisapanacea.Theyshouldbegivenforthreetosixmonths,thenreassessed.Inpatientswithexacerbationsrelatedtostress,amitriptyline100-150mg,atnight,intro-ducedgradually,isofteneffective.Whichofitsactions-sedative,antidepressant,anti-serotoninergic,orcalciumchannelblock-ade-isimplicated,isnotknown.fl-blockerswithoutintrinsicsympathomimeticactivitypropranolol,'30atenolol,andmetoprolol-reducethefrequencyinabout60%ofcases,andaremosteffectiveinthetenseorhyper-tensivesubjectwithtachycardiaandovertphysicalsignsofautonomic"overdrive".Theiractionisprobablycentral.Serotonininhibitorsarevaluablein60-70%ofpatients.Cyproheptadine4mgthreetimesdailyinhibitscalciumchannels,andserotoninandhistaminergicactivity.Pizotifen05mgthreetimesdailyor1-5mgatnightismoderatelyeffectiveandfreeofhazardsotherthansedationandweightgain.3'Methysergide1-2mgthreetimesdailyisthemosteffectivedruginthisgroupbutshouldbeusedunderhospitalsupervisionincoursesnotexceedingthreetofourmonths.Pleural,pericardial,andretroperitonealfibro-sisarerarebutserious,sideeffectsthatresultfromprolongeduse;theyusuallyregresswhenthedrugisstopped.Myocardialandperipheralvascularischaemiaareuncommoncomplications.Althoughcalciumantagonistscancauseavasodilator-typeheadache,some-forexample,flunarizineandverapamil,havebeenestablishedasusefulprophylacticdrugs.32MenstrualmigraineMenstrualmigraine,definedasoccurringexclusivelywithin48hoursofmenstruation,isuncommonbutmayberelievedbysuma-triptan,oroestrogenpatchesorimplants.Migrainebetweenperiodsbutworsewithmenstruation,iscommon(35%)butresistanttodiureticsandhormonalmanipulation.CLUSTERHEADACHESynonymsaremigrainousneuralgia,Harris'ssyndrome,andHorton'ssyndrome.Oftenmisdiagnosed,thisisadistinctsyn-dromeseparablefrommigraine;itpredomi-nantlyaffectsmen(male:femaleratio10:1).Itbeginsatanyage,mostoften20to50years,andismanifestasdailyboutsofunilat-eralheadacheofgreatseveritylasting30-120minutes.Thebrevity,severity,lackofaura,andvomitingoccurringdailyinclusters,last-ingusuallyfor4-16weeks,clearlyseparateitfrommigraine.Thepainisboring,aching,orstabbingandiscentredononeorbitwithradiationtotheforehead,temple,orcheekandjaw("lower-halfheadache").Itcharac-teristicallystrikesatnight,anhourorsoaftersleep,andmayrecurduringtheday

,oftenatthesametime("alarm-clockheadache").Inmanycasestheipsilateraleyebecomesredandbloodshot,wateringprofusely.Thenostrilmaybeblockedorrun.AtransientHomer'ssyndromeisseenin25%ofcasesandoccasionallypersists.Restlessness,crying,andheadbangingbetraythefrighteningseverityofthepainand,incontrasttomigraine,mostpatientsgetoutofbedandpacethefloor,eventakingnocturnalwalks.Alcoholandothervasodila-torsprecipitateattacks:nitroglycerineisuse-fulasaprovocativetest-atypicalattackfollowingwithinanhourofasublingual0.5mgtablet."Acuteepisodiccluster"lastsforonetofourmonthsalthoughoccasionallytheycontinueforayearormore,whenitis139 PearceTable4DiagnosticciteriaforclusterheadachesEpisodic(a)Atleastfiveattacksfulfilling(b)-(d)(b)Severeunilateralorbitalorsupraorbitalpain,withorwithouttemporalpain,lasting15-180minutesuntreated(c)Headacheisassociatedwithatleastoneofthefollowingsignswhichhavetobepresentonthepainfulside*Conjunctivalinjection*Lacrimation*Nasalcongestion*Rhinorrhoea*Foreheadandfacialsweating*Miosis*Ptosis*Eyelidoedema(d)Frequencyofattacks:fromoneeveryotherdaytoeightperday.(e)Historyand/orphysicalandneurologicalexaminationsdonotsuggestotherdisordersassociatedwithheadtraumaChronicAttacksoccurformorethanoneyearwithoutremission,orwithremissionlastinglessthan14days.Theattacksareclinicallyindistinguishablefromepisodicclusterheadache.knownas"chronicmigrainousneuralgia".Remissionsarecompletebuttheclustersrecureveryyearortwo.Thequality,timing,duration,anddistributionofpainseparateitfromtrigeminalneuralgia,migraine,andothercephalgias.Thereisnofamilyhistory,anditisuncommonforapatienttohavebothmigraineandclusterheadache.Thereisanunexplainedhighincidenceofpepticulcer."Thediagnosticcriteria(IHS)aresum-marisedintable4.TreatmentTheaimispreventionofattacks.'4Duringclusters,alcoholisprohibited.Ergotamineisgivenonehourinanticipationofdaytimeattacks,andatbedtimefornocturnalattacks.Suppositoriesarethemostusefulpreparation.Controlisgoodin75%patientsandthedrugisstoppedeachSundaytoseeiftheclusterre-emerges;ifso,ergotamineiscontinuedforafurtherweek,untiltheclusterends.Ifergotisunsuccessful,sumatriptan6mgsubcuta-neouslyor100mgorally,22methysergide1-2mgthreetimesdailyorverapamil40-80mgthree.timesdailyareusefulalterna-tives.Oxygen5-10litresperminutefor10minutesattheonsetisofteneffective29butf/-blockersandpizotifenarenot.Lithiumisusefulinthechronicvariantifothermethodsfail.Inintractablecases,ashortcourseofsteroidsoftenprovidesrelief.Surgeryissel-domindicated,buttrigeminallesionsmeetwithoccasionalsuccessinrefractorypatients.ChronicparoxysmalhemicraniaThisisararevariant35ofclusterheadache,occurringpredominantlyinfemales,withidenticalattacks,oftenfiveto20perday,whichlastfromthreeto15minutes;theyrespondalmostinvariablytoindomethacin,75-150mgdaily.CERVICOGENICHEADACHEHeadpainreferredfromcervicalspondylosisisundoubtedlycommon,withpainononeorbothsidesoftheneckradiatingnotonlytotheocciputbutalsotothetemplesandfrontalregion.Itmaybeadull"toothache"pain,worseinthemorningwhentheneckhasbeeAnkinkedonhighpillowsduringsleep;itcaninitiatemigraine.Itcanlastthroughouttheday,aggravatedbyneckmovementandtensionandisanondescriptpain,withoutaccompanyingvomitingorphysicalsignsotherthanrestrictionoflateralflexionandrotationoftheneck.Suchsignsarecommon,however,inthosewithoutheadache.Vagueandintermittentsymptomsoftinnitus,dizzi-ness,andvisualdisturbancearesometimesattributedtocompression-ofthevertebralarteries,butthisisunproven.PainarisesfromtheposteriorzygapophysealjointsandrelatedligamentsastheresultofosteophyteswithirritationoftheC2rootorgreateroccipitalnerves.36Manipulationendangerstheverte-bralarteriesandiscontraindicated.Collarsarecomfortingbutoflittlevalue.Injectionsofthefacetjointregionanatomicallyrelatedtopainwillinduceusefultemporaryremissioninabout70%ofsubjects.37Hydrocortisone25mgormethylprednisoloneareused,with1mlof2%lignocaineonthreeoccasionsatweeklyintervals.Thebenefitmaywaneinafewmonths,whentheinjectionscanberepeated.GIANTCELLARTERITISSynonymsarecranialortemporalarteritis.Thisconditioniscruciallyimportantasatreatablecauseofheadache,itisalsoapre-ventablecauseofblindnessandstrokes.Thediagnosticfeaturesareshownintable5.Painisgeneralisedormaybesitedovertheclassic,butrare,reddened,tender,superficialtemporaloroccipitalartery.Thehistoryisofafewweeks'duration.Thepatientisunwellwithachesandpainsintheshoulderandpelvicgirdlemuscles(polymyalgiarheumat-ica)andtheremaybefever,sweats,andmas-seterclaudication.Visualinvolvement(50%patients)isduetoanischaemicopticneu-ropathywhichpresentswithunilateralblind-nessorduetoabranchretinalorciliaryocclusionandisirreversible.P

osteriorcere-bralarterylesionscauseahemianopia.Ophthalmoplegiaanddiplopiamaybethepresentingsign,basedonischaemiclesionsinthethird,fourthorsixthcranialnerves,beforetheonsetofheadacheandmalaise:hencetheimportanceofearlydiagnosis.Itaffectsthevertebral,andlessoftenthecarotid,arteriesandmaypresentasastrokeortransientischaemicattack.Everyelderlysubjectwithrecentheadachesorunilateralvisuallossshouldbesuspectedofharbouringthiscondition.Serialerythro-cytesedimentationrates(ESR;usuallyTableSDiagnosticcriteriaforcranialarteritis38*Age�50yearsatonset*Newonsetoflocalisedheadache*Temporalarterytendernessordecreasedtemporalarterypulse*ElevatedESR�50mm/h*BiopsyshowingnecrotisingarteritisThepresenceofthreeormoreofthesefivecriteriaprovidesasensitivityof93-5%andaspecificityof91-2%.Scalptender-nessandclaudicationofthejawortongueorondeglutitionincreasessensitivityto953%ESR=erythrocytesedimentationrate.140 Headache70-120mm/h),sometimessupplementedbyanadequatebiopsyoftheclinicallyaffectedscalpvessel,whichshouldbeseriallysec-tioned,willprovethediagnosis.CranialarteritismayspontaneouslyremitandtheESRthenfalls;thusasingle,normalESRdoesnotexcludearteritis.Biopsyisindicatedinclinicallyborderlinecases.Atypicalpresentationsthatshouldpromptassiduousinvestigationinclude:(a)patientswithminimalheadache;(b)headacheinanappropriatelyagedpatientwith,initially,anormalESR;(c)feverofunknownorigin;(d)psychiatricsymptomsofhallucinations,depression,and"confusionalstate";(e)iso-latedthirdorsixthnervepalsy;rarelyinter-nuclearophthalmoplegia.Steroidswillavertblindnessinalmosteverycase,andshouldbestartedimmediatelythepatientisseenandthebloodsampleforanESRtaken.Theydonotaffectthebiopsychangesforatleast48hours.Headachesoftenabatewithin24hoursoftreatment.Theinitialdoseof-60mgprednisolonedailyisquicklyreducedassymptomsabateandtheESRfalls.Themaintenancedoseof5-10mgdailyisusuallyreachedwithinamonthortwoandisgovernedbyclinicalprogressandESRmeasurements.Laterelapsesarecommon39andtreatmentmayberequiredformanyyearswithgradualreduc-tionsby1mgpermonth,onlywhenthepatientandtheESRhave'beennormalforovertwoyears.Inmany,smalldosesarenec-essaryforlife,asprovedbyseriousrelapsesmonthsafterthedoseofprednisoloneisreduced.39HYPNICHEADACHE(SOLOMON'SSYNDROME)Thisisacuriousheadache,seenmainlyinthoseover60years.Patientsarewokenbypulsatingheadache,sometimesaccompaniedbynausea,atthesametime,onetothreetimeseachnight.40Thisoccursmostnights,lastsabout30minutesandmaycoincidewithrapideyemovementsleep.Itisuncommonanddiffersfromchronicclusterheadacheinage,generalisedlocation,andabsenceofautonomicfeatures.Therearenophysicalsignsandthedisorderis-benign.Theresponsetolithiumcarbonate300mgatnightisoftenspectacular.POST-TRAUMATICHEADACHEANDITSMANAGEMENTHeadacheafterheadinjuryisacommoncomplaint.Inmostcircumstancesaknockontheheadwillcauselocalbruisingandabra-sionsnodifferentfromthoseresultingfromakickontheshin;localpainsubsidesinthreeto10dayswithoutsequelae.Theemotionalvulnerabilityoftheheadandtheeasyrecoursetomedicolegalcompensationcom-plicatebothsymptomsandmechanisms.Manyvictimsofsevereheadinjury,withpost-traumaticamnesiaof24hoursormore,wakenwithnoheadache.Similarly,theheadacheofpatientsaftermajorcraniotomyseldomlastsmorethanthreetosevendays.Thecommonestcomplaintsareheardfromthosewithminorinjury(lossofconsciousnesslessthan20minutes;Glasgowcomascore13-18;stayinhospitallessthan48hours).Despiteminorcognitivedeficits,mostcasesleavehospitalwithinafewdays,havenoorganicsigns,recoverquickly,andreturntoworkwithoutfurthercomplaints.Thisispar-ticularlytrueofthosesufferinginjuryduringcontactsports.Attributable,post-traumaticheadachespersistforafewweeks,andsel-dommorethansixmonths,unlesscompli-catedbyotherissues.Themainconcernofphysiciansistheassessmentofsymptomsinthosewithhead-acheswithoutaccompanyingneurologicalsigns,butoftenwithacollectionofintrinsi-callysubjectivesymptomsoftencalledthe"post-traumaticsyndrome".Thecomplaintsare:forgetfulness,irritability,slowness,poorconcentration,fatigue,dizziness(usuallynotvertigo),somnolence,intoleranceofalcohol,light,andnoise,lossofinitiative,depression,anxiety,lossofinterests,andimpairedlibido.Thenumberofcomplaintsisofteninverselyrelatedtotheseverityoftheinjury.In2493individualsexaminedaspartofanationwidegeneralpopulationsurvey,post-traumaticstressdisorderwasfoundin1%ofthetotalpopulation,about3-5%inciviliansexposedtophysicalattackandinVietnamveteranswhowerenotwounded,and20%inveteranswoundedinVietnam.42Althoughhyperalertnessandsleepdisturbances,occurredcommonlyinthegeneralpopula-tion,thefullsyndrome(DSP&-III-R)wascommononlyamongveteranswoundedinV

ietnam.Thisarguesagainstthevalidityofthewidespreaduseofthislabelinthosesub-jectedtominorinjuries.Traumaprobablynevercausesmigraine,butpre-existingmigrainemaybetemporarilyworse,usuallyforuptothreetosixmonths,probablyasanon-specificreactiontostressortodisabilities.43Thefailureofdoctorstoprovidecompletereassurancesoonafterinjuryisimportantindeterminingpatients'fearsofbraindamageorsubduralhaematoma;italsodelaysreturntoworkandinducesiatrogenicmorbidanxi-ety.Headachesareatthesiteoftrauma,oftenwithscalptenderness,ormoreoften-liketensionheadaches-arediffuse,aching,tight,orheavy.Theyresistanalgesics,andinvesti-gationsinmostpatientsarebothunrevealingandunwarranted.Headachessometimesimprovewhenthepatientiscounselledandreturnstowork,butdonotinvariablydisap-pearevenwhensatisfactorysettlementisattained.Anxieties,phobias,lossofselfesteem,resentment,anddepressionaregen-uineaccompanyingfeaturesinsomecases,andservetoinduceortoaggravateheadache.Deliberateexaggeration,ormalingeringinoccasionalcases,aremotivatedbyquestforattentionandfinancialgain.Inlitigantsthereisgreatpressurefromtradesunionofficialsandlawyerswhich,togetherwiththecom-mondelayinsettlement,servetoprolongandexaggeratethesymptoms.141 PearceTable6SimplifiedplanofmanagementforheadachePatientpresentswithheadachesofabruptonset*Excludetrauma.Ifsignsofmeningealirritation,suspectintracranialhaemorrhageormeningitisandadmittohospital.PerformCTorMRIand,ifnotumour,haematoma,orhydrocephalusfound,performlumbarpunctureNB:lumbarpuncturewithinsixhoursoftheictusmaymissanearlybleed*Ifnosignsofmeningealirritation,consideramasslesion,arrangeCTorMRIandrefertoneurosurgeryifnecessaryPatientpresentswithincreasingheadache,shorthistory*Excludelocalcranialpathology,suchasglaucoma,sinusitis,dentaldisease;lookforsignsofraisedintracranialpressure,suspectmassorhydrocephalus.ArrangeCTorMRIbeforelumbarpuncturePatientpresentswithchronicorintermittentheadachewithnoneurologicalsigns*Excludelocalcranialpathology:glaucoma,sinusitis,dentaldisease.Ifcontinuous,suspecttensionheadache;ifparoxysmal,suspectmigrainewithorwithoutaura.Lookforfeaturesofclusterheadache,otherheadachesyndromes,andcranialneuralgiasPOST-HERPETICNEURALGIAThisdreadedcomplicationoftrigeminalher-peszoster,particularlycommonintheelderly(50%ofover70s)andrareundertheageof60,isdefinedbypainpersistingformorethanonemonthaftertheeruption.Two-thirdsspontaneouslyrecoverinoneyear,leavingaminoritywithprotractedandintractablepain.Errorsindiagnosisareavoidedbyinsistingonthepresenceofhealedpost-herpetichyperpigmentedordepigmentedareas,orboth,inasegmentaldistribution.Anunderlyingneoplasmoftheaffectedrootsandsystemicimmunosuppres-sionshouldbeexcludedbyjudiciousinvesti-gation.MThemechanismofpainisuncertain.Thepreferentiallossoflargediameterneurons,accordingtothe"gatetheory"ofMelzackandWall,permitsincreasedtransmissionofnociceptiveinformationthroughthedorsalhorn,thusevokingpain.Therecanbenogeneralrecommendationforacyclovirorsteroidsintheacutestages,butinthefrailandelderlywhoarehighlyvulnerable,itmaybejustifiabletoemploybothdrugs44attheonsetofherpeszosterinfectioninanattempttoavertthispotentiallygraveaffliction,inwhichsuicideiswell-known.Intheestab-lishedcase,symptomaticimprovementisdis-appointing.Itisworthtryingtricyclicsbuildingslowlyuptohighdoses(suchasimipramineoramitryptiline125to200mgdaily).Additionalregularnon-opiateanal-gesicsbydayand,inseverecases,oralmor-phineorheroinatnightwilloftenbejustifiable.Localcounterirritants,nowcalled"neuroaugmentation",intheformoffreezingspraysortopicalcapsaicin0-025%creamcanbehelpful.Transcutaneouselectricalnervestimulatorsfindoccasionalsuccess.ConclusionMostheadachespresentingtothegeneralpractitionerandhospitalphysicianhavenoominousintracranialcause,butareasourceofsufferingandlossofworkingtime.Manyheadachesareinfrequentandself-limiting.Apainstakingclinicalapproachbyagoodlis-tenerwillresolvemanyproblemsandwillpreventtherefractorycourseinsomeofthoseinwhomacursoryinitialexaminationfailstosecurereassurance.Patientspresentingprob-lemsindiagnosis,andthoseunresponsivetoappropriatetreatmentwillbenefitbyreferraltoaneurologist.Table6showsasimplifiedplanofmanage-ment.1StangPE,YanagiharaT,SwansonJW,etal.Incidenceofmigraineheadache:ApopulationbasedstudyinOlmstedCounty,Minnesota.Neurology1992;42:1657-62.2IntemationalHeadacheSociety.Classification.Diagnosticcriteria.Cephalalgia1988;8(suppl7):19-45.3RasmussenBK.Migrainewithauraandmigrainewithoutaura:Anepidemiologicalstudy.Cephalagia1992;12:221-8.4RasmussenBK,JensenR,OlesenJ.Impactofheadacheonsicknessabsenceandutilisationofmedicalservices:ADanishpopulationstudy.JEpidemiolCo

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