Perhaps the most ubiquitous of all neurologic symptoms, headache remains a challenge for many neurologists. When to suspect something more than a benign headache syndrome and thus embark on a costly workup is one critical question to be answered. Because many people with headaches never seek medical attention and instead successfully self-manage their symptoms, the patient who presents to the neurologist invariably warrants serious attention. Individuals with persistent or intractable headaches represent a particularly vexing problem. In this issue of Continuum: Lifelong Learning in Neurology Guest Editor Mark Green and his team of expert contributors address these, and many other, questions.
Asked to free-associate on the word headache, many neurologists would undoubtedly respond migraine, for this is perhaps the most recognizable headache syndrome and one that still remains enigmatic. Its recognition and successful management can provide not only very welcome relief to the patient but also gratification for the neurologist. It is only fitting, therefore, that Dr Thomas Ward kicks off this issue with his discussion of the diagnosis and pathophysiology of migraine. Dr Paul Rizzoli then discusses the two key elements of migraine management—abortive treatment of acute attacks and prevention. In a subsequent article, Dr Alexander Mauskop educates us about alternatives to prescription medications for treatment of migraine. He emphasizes nonmedication management as well as alternative and complementary medicinal agents that patients with migraines may try.
The conundrum of “tension-type headache” is epitomized by its very name, reflecting the imprecision of our knowledge of the mechanism of this common headache type. The increasing recognition of the overlap between tension-type and migraine headaches and the frequent mislabeling of the former further complicate our understanding of this entity. These issues, among others, are discussed by Dr Robert Kaniecki in his article on tension-type headaches.
In an attempt to gain relief from headaches, many patients tend to take analgesics in large quantities. Not a great idea! Many individuals who develop seemingly intractable headaches have these headaches precisely because of the medications they have been overusing. Dr Stewart Tepper addresses this important issue in his article on medication-overuse headache, in which he confronts the difficulties of managing these patients, which invariably depend on successfully weaning them from the offending agents.
As suggested above, the neurologist must recognize the danger signals that suggest more ominous headaches. Dr Green himself tackles this subject in his article on secondary headaches. We are often reminded that children are not simply little adults. Dr Shannon Babineau, along with Dr Green, emphasizes the differences in an article on headaches in children.
Facial pain and neck pain have an intimate relationship to headache. In and of themselves these entities pose their own differential diagnoses and management issues. Dr Steven Graff-Radford illuminates these often perplexing subjects. Among the more fascinating headache syndromes are those that are accompanied by features of autonomic dysfunction in cranial nerve distributions. Dr Peter Goadsby elucidates these unusual entities, including cluster headache, paroxysmal hemicrania, and short-acting unilateral neuralgiform headaches, in his article on trigeminal autonomic cephalalgias.
In addition to the review articles in this CONTINUUM this issue, Drs Joshua Kornbluth and James Russell present an interesting ethical dilemma in which physician integrity trumps a request for questionable coding that might yield greater revenue for a hospital. This Ethical Perspectives article dovetails nicely with the thorough review of coding for headache presented by Drs Stephen Silberstein and Laura Powers in the Practice Issues section. Although usually considered a benign condition, migraine can, at times, be disabling. Because of the absence of physical signs, patients may face particular challenges in attempting to qualify for disability benefits. Dr Robert Shapiro discusses the important issue of disability rights for patients with migraines in this issue’s Practice Issues case discussion.
As usual, this issue of CONTINUUM offers ample opportunity for you to earn continuing medical education credits. Armed with the knowledge you gained from Dr Goadsby’s article, you should be well prepared to tackle the Patient Management Problem, crafted by Dr Sylvia Lucas. Many of the Multiple-Choice Questions, prepared by Drs Eduardo Benarroch and Adam Kelly, offer the opportunity for you to apply your headache expertise to specific clinical scenarios. They will indeed enhance your educational experience.
Thanks to Dr Green and his expert colleagues you will be much better equipped to understand and manage the patient with difficult headaches. No longer will you need to resort to the time-honored, but usually inadequate, advice, “Take two aspirin and call me in the morning.”
—Aaron E. Miller, MD