When you're lying awake with a dismal headache, and repose is tabooed by anxiety, I conceive you may use any language you choose to indulge in, without impropriety.
Sir William Schwenck Gilbert
These words, penned for Gilbert and Sullivan's operetta Iolanthe, so often characterize the chagrin experienced by the headache sufferer who presents to the neurologist's office. Comparable vexation may afflict that neurologist who confronts a patient with a difficult headache problem. Relief is on the way!
In this issue of Continuum, Drs Joel Saper and Todd Rozen have assembled a talented group of colleagues to lead us toward better understanding, improved diagnosis, and optimal care of headache sufferers. The unusual heft of this edition of Continuum reflects the ubiquity of the symptom and the importance of headache in the general neurologist's practice.
Classifying disorders for which objective signs, both on physical examination and through imaging studies or other investigations, are generally lacking is inherently difficult. A variety of opinions usually ensue, and sometimes the end result resembles that of the proverbial camel, described as a "horse designed by committee." Nonetheless, appropriate classification is important for the neurologist, even if it is sometimes difficult to precisely pigeonhole a patient. Dr Morris Levin helps guide us through the controversies and better understand the current, although undoubtedly not the ultimate, classification.
Migraine, arguably the most important primary headache in terms of its frequency and impact, justifiably garners extensive attention in this issue. Drs Richard Lipton, Sandra Hamelsky, and Marcelo Bigal review the epidemiology of migraine; Dr Peter Goadsby provides a clear discussion of its pathophysiology; and Drs William Young and Stephen Silberstein detail the symptoms and diagnostic process. Treatment of migraine often requires a dual approach with a focus on both acute (or abortive) therapy and, in more frequently or severely afflicted individuals, a preventive strategy. Dr Stewart Tepper provides the optimal approach to the former, and Drs Young and Silberstein discuss the latter.
A major focus for headache specialists in recent years and a condition that frequently results in referrals to headache centers has been chronic daily headache. Medication overuse headache (a condition that has often been labeled with other terms such as "rebound headache") is heavily represented in this population but is not the only etiology for chronic daily headache. Drs Bigal and Fred Sheftell review these subjects in order to help neurologists understand the classification and improve their diagnostic and treatment skills.
Neurologists have long recognized cluster headache, one of the most dramatic headache syndromes. But more recently, a variety of other syndromes, which share some features with cluster, have been described. These headaches have now been grouped under the rubric of "trigeminal autonomic cephalalgias," thoroughly reviewed herein by Dr Rozen.
A nightmare for most neurologists is the thought of mistakenly considering a headache of secondary cause as a primary headache. Dr Randolph Evans provides guidance that will help us avoid this trap, and Drs Todd Schwedt and David Dodick review the relationship between headache and stroke or heart disease.
Patients with chronic pain-and headache epitomizes the situation-are notoriously difficult to manage. They are commonly affected by significant psychiatric problems, be they cause or effect of the underlying pain syndrome. As a result, successful management of the patient with chronic headache requires an approach that encompasses much more than simply prescribing a medication. Alvin Lake, III, PhD, enables us to better understand and deal with the complex psychological issues in this population. Dr Saper wraps up with a cogent summary, review, and approach to the patient with intractable headache.
This issue of Continuum also features a discussion of the ethical issues surrounding narcotic use provided by Dr Peter Jacobson and incisive questions crafted by Drs Ronnie Bergen and Julie Hammack, as well as a patient management problem in which Dr Rozen reinforces the lessons on trigeminal autonomic cephalalgias.
Finally, we provide a Quintessentials module that should enable neurologists to assess their own practice in managing headache patients. This is a very practical tool that supplements the material provided in Continuum itself.
We are indebted to Drs Saper and Rozen and their distinguished faculty for their contributions to our understanding of headache. This issue of Continuum contains much to digest. The effort will be well rewarded.
Aaron E. Miller, MD, FAAN