A. Theoretical considerations considerations for migraine migraine therapy. therapy. The current theories of migraine are based on the model of neurovascular inammation in the trigeminal nerve distribution (for reference, see Goadsby et al.). In brief, trigeminal nerve endings on cranial vessels release calcitonin Grelated peptide (G!"), neuropeptide y, and a nd substance " producing vasodilatation and plasma protein e#travasation and stimulation of pain receptors. The pain signal is transmitted through the trigeminal nerve to the trigeminocaudal nucleus (T$), thalamus, and then to the corte#. %odulation of this signal can occur at each of the synapses. &ensiti'ation can occur seuentially at peripheral and central neurons, enhancing the pain perception. &preading depression depression (&) is postulated to be the pro#imate event that initiates the neurovascular process in cerebral and meningeal arteries, and may also initiate other neural events related to migraine. The trigeminovascular nerve endings have presynaptic serotonin (*+T) (*+T) receptors, hich can inhibit release of neurotransmitters and modulate the neurovascular response and pain transmission. tr ansmission. "resynaptic *+T- *+T- receptors e#ist on serotoninergic connections to central neurons and may modulate central pain transmission. /ther systems are involved, but the discussion is beyond this brief summary. summary. /f note, the central centra l dopaminergic system appears to facilitate migraine development. To oversimplify, it appears that serotonin , agonists ameliorate migraine, hereas dopamine agonists e#acerbate the process. . linical considerations for therapy of headache. The most important aspects of headache treatment are0 () correct diagnosis, (1) demonstrating interest in the patient2s problem, (3) 4noledge of the available approaches to treatment including pharmacological and nonpharmacological, and (5) commitment to ongoing follo-up ith the patient. The primary headaches are typically recurrent or chronic and the patient ill reuire continued attention and follo-up over variable periods of time. 6or the patient, having a compassionate, interested physician is an asset of great value.
A ma7or aspect of therapy is having adeuate data on hich to base decisions. The ma7or ongoing parameters of headache are freuency, duration, and intensity, as ell as symptoms associated ith the headache. &uccess in therapy may be measured in any of these dimensions but usually in the 8rst three. The temporary disability produced by the headache is often a measurement that can be easily understood by the patient and can be measured as0 disabling9the patient must be in bed or inactive :;<= of time during the headache, severe9activity is diminished by *<= to ;<= of usual, moderate-mild9 more than *<= of usual activity is possible. +aving the patient 4eep a calendar of their headache occurrences and an indication of the severity and duration of the headache is a great help in the follo-up visit. The calendar ill provide a rapid assessment of the interval headache problem since the last visit and allo assessment of progress. 6igure 6igure 5;. above shos a simple calendar based on occurrence and disability that can be used.
