Abstract
In its effort to elevate the level of scientific discourse in the field of Headache, challenge its readers, and introduce new educational platforms, the journal introduces a series of debates on several of the most important and controversial issues which are germane to the fundamental understanding of the scientific basis of migraine and the treatment of one of the most common and challenging groups of patients seen in clinical practice.
In the first debate, Professors Andrew Charles and Messoud Ashina reflect on the primacy of the blood vessel in the generation of the migraine attack. In their erudite review of the evidence base that has accumulated since the 2nd century, they have reframed the historical construct of the ‘vascular hypothesis’, provided opposing yet compelling arguments on the primacy of the blood vessel and central nervous system in the generation of both aura and headache phases of an attack, and illustrate that these arguments are not mutually exclusive. The potential for intraluminal factors and alterations in calibre or flow to trigger attacks seems plausible in certain genetic vasculopathies and for specific triggers, while the complexity of the premonitory phase and emerging neurophysiological and functional imaging evidence that the ‘interictal brain’ in individuals with migraine is altered, suggests that alterations in cerebral blood flow or calibre is related to neurovascular coupling.
In the second debate, Professors Olesen and Diener dispute the role of acute medication withdrawal (‘detoxification’) in patients who ‘overuse’ acute medications according to the definitions proposed by the ICHD-2. The striking difference in the interpretation of the evidence base and the contrasting clinical approaches to this patient population is remarkable. It is clear that the clinical divide over the management approach to a highly disabled patient population who have long constituted a large proportion of clinical headache practice underscores the need for more definitive long-term studies. It is also clear that while there is disagreement over the extent to which acute medication overuse is the cause versus the consequence of frequent headache, there is little disagreement that minimizing the consumption of acute medications will minimize the potential for systemic organ toxicity and is good medicine.
These debates from leading thinkers and luminaries in the field, while leaving the readers with compelling and opposing viewpoints, will help inform clinical decision making, provide valuable insight and perspective into hotly contested issues in headache science and medicine, highlight gaps in our understanding, and identify important areas of future research. The editorial board and our readers are grateful for these contributions.