Headache has come a long way during the seven editions of this book, in part because of the issues

raised by its first author. Understanding headache is a challenging task given the large number of headache syndromes; the current International Headache Society (IHS) classification runs to 96 pages (Headache Classification Committee of the International Headache Society, 1988). However, understanding the mechanisms of headache is time well spent given the common nature of headache problems (Rasmussen, 1995; Stewart et al., 1992) and the expansion of treatments, particularly for migraine, that has taken place in the last few years (Goadsby and Silberstein, 1997). The emphasis in this section is on the primary headache syndromes, which are very common and, while not life-threatening, are lifestyle-disabling. After dealing specifically with migraine and cluster headache, the issues of the blood vessels, so close to Wolffs interests (Graham and Wolff, 1938, 1966; Ray and Wolff, 1940; Tunis and Wolff, 1953), and tension-type headache will be addressed. General Principles Headache is an excellent example of a problem that spans the breadth of medicine. It can be at once a major symptom, such as in subarachnoid hemorrhage, and the most disabling aspect of a primary syndrome, such as in cluster headache. Headache may be divided into primary headache, in which the headache and any associated features are themselves the disease processes, and secondary headaches, in which the headache is a symptom of an underlying disorder. Much of the basic anatomy of all types of headache must be shared, since ultimately the trigeminal nucleus transduces nociceptive information from the head prior to its distribution within the brain. The best described anatomy and physiology have been developed in the investigation of migraine, but much of this substrate must be shared. Since secondary headache processes entrain very similar mechanisms for the expression of pain or even trigger primary headache mechanisms, it is not surprising that a secondary headache can mimic a primary headache phenotype and provide a very substantial diagnostic challenge. ============= Migraine Migraine is, in essence, an episodic headache that has certain associated features (Table 5 - 1), which give the clues to its pathophysiology (Table 5 - 2). In addition the term migraine is often used in two ways: first, to refer to the phenotype attacks, and secondly, to imply the underlining biotype of a headache disorder. It is interesting to compare the features of migraine and tension-type headache and to ask What is quintessentially migrainous? How can we make the diagnosis based on understanding the elements that contribute to the dysfunction? The essential aspects to be considered in understanding migraine are as follows:

Anatomy of the large intracranial vessels and dura mater and their neural connections, which are known as the trigeminovascular system

The physiology and pharmacology of activation of the peripheral branches of the ophthalmic branch of the trigeminal nerve as marked by plasma protein extravasation and neuropeptide release

The physiology and pharmacology of the trigeminal nucleus, in particular its caudalmost part, the trigeminocervical complex

The brain stem and diencephalic modulatory systems, which control trigeminal pain processing

Table 5 - 1 Simplified diagnostic criteria for migraine: comparison with tension-type headache (repeated attacks of headache lasting 4 to 72 hours or 30 minutes to 7 days for tension-type headache, which have these features) Migraine At least 2 of the following Unilateral pain Throbbing pain Aggravation by movement Moderate or severe intensity At least 1 of the following Nausea/vomiting Photophobia and phonophobia Tension-type headache

Bilateral pain Nonthrobbing pain No effect of movement Mild or moderate intensity

No nausea/vomiting Photophobia or phonophobia but not both