Abstract
It is good news that Cephalalgia is now thirty years old. Its success from the beginning was due to the hard work and skill of its first editor Ottar Staastad.
Interest in migraine and headache had been increasing in the 1950s and many distinguished physicians and scientists such as Brain, Critchley, Sicuteri Anthony, Lance, Dalsgaad-Nielson, Ekbom, Saxena, Isler, Graham, Friedman, Diamond and many others were all taking an interest.
In 1965 the Migraine Trust chaired by Lord Brain was formed and a committee set up. One of their first decisions was that there should be a migraine clinic in London where patients who were in the process of having a migraine could go, because at that time very few headache specialists had actually seen patients in an acute attack. The City of London Migraine Clinic was founded in the late sixties. Many important papers were being written by Scandinavian, British and other authors interested in migraines and these were often rejected by the neurological journals. So Cephalalgia came at a very opportune time.
In the past thirty years most of the leading workers in the migraine and headache field have contributed articles to Cephalalgia and it is now regarded as the best journal for papers on this subject. Despite all this there still remains a great deal that is not known about migraine and its treatment. Some of the unanswered questions seem very simple, but there are no easy answers to any of them. What is migraine? In the classification the symptoms are described, but the actual pathological process is not known, although many theories have been put forward.
What initiates an attack of migraine? Again there are multiple precipitating factors mentioned, almost as many as there are migraine patients, including stress, flashing lights, chocolate, onions, bad diet, menstruation and so on. What is the mechanism of the attack? Again, many theories have been put forward, one of the most popular being spreading depression. Others include vascular changes or chemical disturbances, but so far there is no definite answer.
In a migraine attack the neurological symptoms, usually visual disturbances, indicate brain activity. Why does there seem to be little if any mental deterioration after tens or hundreds of attacks with major neurological symptoms? Some patients may suffer from migraine for over fifty years starting with headache, nausea and vomiting as children and ending up with attacks of mainly visual disturbances, such as teichopsia, fortification spectra or central scotoma, but showing relatively little if any mental deterioration.
The mystery of migraine is why these and other similar questions are still not answered – many good physicians and scientists are involved in the quest for answers and many of their papers have been in Cephalalgia, which for three decades has been a vital part of the migraine and headache field. One possible reason is the unreliability of the diagnosis in many of the papers. There is a good classification of migraine and if the diagnostic criteria are rigidly adhered to all will be well; but much of the material analysed has not been obtained by a physician: some of it has even been volunteered by people over the telephone who say they have migraine, and the information has been recorded by a lay helper. Another difficulty, in addition to a misdiagnosis, is that the person may suffer from more than one type of headache. History taken by the physician is essential if a correct diagnosis is to be made, because often what the patient does not say is nearly as important as what he or she does mention, and the patients wittingly or unwittingly mislead the doctor. I appreciate that talking to the patient is now often considered a waste of time, but in my opinion it is the only way to obtain accurate information on a condition for which there are few physical signs or definite chemical or scan abnormalities.
While Cephalalgia exists, members of the headache community have the best possible way of sharing their knowledge and obtaining the benefit of others' expertise.
Long may it continue.