Triptans revolutionized medical recognition and the acute treatment of migraine. Yet, throughout a lifetime, millions of patients who live with migraine endure hundreds of days of disability due to their disease. Most migraine attacks respond to migraine-specific interventions, but attack response does not predict patient response. Generally, migraine patients respond to acute treatment for some, but not necessarily all, attacks of migraine. Consequently, there remains a substantial unmet clinical need for better acute treatment of migraine.

Numerous avenues of research and clinical observation provide insight into potential advances in acute treatment of migraine. These include better delivery systems for existing drugs, as well as the development of potential new therapeutic agents. In addition, new changes in migraine taxonomy and clinical observations of migraine suggest additional important therapeutic opportunities. Based on clinical observations, this article explores future acute treatment needs, drugs in development for acute migraine, and new products that deliver established drugs to improve treatment response.

Some children have visual disturbances that occur in the absence of, or are out of proportion to, their objective ophthalmological findings. These symptoms reflect a wide range of processes that may be benign or a sign of neurological, systemic, or psychiatric disease. This chapter deals with the neuro-ophthalmologic detection of organic and psychogenic disorders that may manifest as transient or unexplained visual loss of the same episodic visual disturbances that occur in childhood, but several formidable problems confront the physician who is trying to reach the correct diagnosis. The descriptions of episodic visual disturbances and hallucinations in children are less complex in detail than those of the adult population because children have limited vocabulary and limited experiential basis of sensory phenomenon to draw upon.

Chronic migraine is a common and disabling complication of migraine with a population prevalence of about 2%. Emerging evidence suggests that episodic migraine and chronic migraine differ not only in degree, but also in kind. Compared with patients with episodic migraine, those with chronic migraine have worse socioeconomic status, reduced health-related quality of life, increased headache-related burden (including impairment in occupational, social, and family functioning), and greater psychiatric and medical comorbidities. Each year, approximately 2.5% of patients with episodic migraine develop new-onset chronic migraine (ie, chronification). Understanding the natural disease course, improving treatment and management, and preventing the onset could reduce the enormous individual and societal burden of chronic migraine, and thus, have become important goals of headache research. This review provides a summary of the history of nomenclature and diagnostic criteria, as well as recent studies focusing on the epidemiology, natural history, and burden of chronic migraine.

Migraine is a common neurological disease affecting about 12% of the population in Western Europe and North America, and causing a considerable burden both to migraineurs and to society. Severe, frequent and disabling migraine attacks, as well as those poorly responsive to acute care medication, require preventive treatment, which is often under-utilized. Antiepileptic drugs are used in the prevention of migraine.

We performed a literature search of PubMed through June 2008 for controlled trials of antiepileptic drugs in the prevention of migraine. The search identified 70 papers for a full-text review. The majority of these papers referred to valproate and topiramate, and showed that these drugs are effective and well tolerated in migraine prevention and are suitable for first-line clinical use. On the other hand, acetazolamide, lamotrigine, oxcarbazepine and vigabatrin have been shown to be not effective and gabapentin requires further evaluation. For the rest of the antiepileptic drugs, no data from controlled trials are available.

Headache is the most common and one of the most disabling types of chronic pain among children and adolescents. At age 5, 20% of children have headache, and by the age of 15, the prevalence of headache may be as high as 82%. We now know more about headache than ever before. Our understanding of headache pathogenesis expanded considerably when the International Headache Society published good diagnostic criteria in 1988 and elaborated in 2004, unfortunately most of these criteria were developed for adults, not children, and therefore our knowledge of pediatric headache has lagged behind what we know about adult headache.Herein we discuss diverse types of pediatric headache, from migraine to the trigeminal autonomic cephalalgias, medication overuse headache, secondary headaches, and more. The issues of pathophysiology, epidemiology, acute and preventive treatment, and non-pharmacological treatments are discussed.The purpose of this chapter is to bring together current information on pediatric headache, recognizing that a more detailed discussion is not possible in this format, but perhaps the reader will be stimulated to explore further any topics of interest presented in this chapter.

Headaches are common disorders and migraine is most intensively investigated due to its high prevalence and often highly disabling character. Many conditions that are likewise prevalent have been described comorbid with migraine, and an increase of many comorbid conditions is seen among those with migraine with aura and higher frequency of headache. Well-established comorbidities include cardiovascular, psychiatric, neurological, and other pain disorders. With regard to cardiovascular disorders an association between migraine with aura and ischemic stroke has been most consistently described. Migraine with aura confers a twofold increased risk. Younger age, female gender, smoking, and oral contraceptive use seem to further raise the risk among migraineurs. With regard to psychiatric disorders, those with migraine are at increased risk of major depression, anxiety, panic disorder, bipolar disorder, abuse and neglect, and suicidal ideation or attempts. Common neurologic comorbidities include epilepsy and restless leg syndrome. Potential explanations for increased comorbidities will be explored. The complex network of an association between migraine and many other comorbid conditions is likely due to shared genetic factors that are further modified by environmental factors.

Background

Modification of expectancies (headache self-efficacy and headache locus of control) is thought to be central to the success of psychological treatments for migraine.

Purpose

The purpose of this study is to examine expectancy changes with various combinations of Behavioral Migraine Management and migraine drug therapies.

Methods

Frequent migraine sufferers who failed to respond to 5 weeks of optimized acute migraine drug therapy were randomized to a 2 (Behavioral Migraine Management+, Behavioral Migraine Management−) × 2 (β-blocker, placebo) treatment design.

Results

Mixed models for repeated measures analyses (N = 176) revealed large increases in headache self-efficacy and internal headache locus of control and large decreases in chance headache locus of control with Behavioral Migraine Management+ that were maintained over a 12-month evaluation period. Chance headache locus of control and socioeconomic status moderated changes in headache self-efficacy with Behavioral Migraine Management+.

Conclusions

The “deficiency” hypothesis best explained how patient characteristics influenced changes in of headache self-efficacy with Behavioral Migraine Management.

The primary headaches carry a substantial hereditary liability, as shown by twin and family studies. Hereditary factors account for an important proportion of the phenotypic variance in migraine with aura (MA) and without aura (MO) and tension-type headache (TTH), while the disease risk is also considerably increased for first-degree relatives of cluster headache (CH) patients. The patterns of inheritance are complex, which means that both genetic and environmental factors contribute. Familial hemiplegic migraine (FHM), a monogenic subtype of MA, has an autosomal dominant pattern of inheritance, and so far can be ascribed to mutations in three genes, CACNA1A, ATP1A2, and SCN1A, all coding for ion channels. Available studies have not provided clear evidence that these genes are also involved in the more common forms of migraine (MA and MO). Genome-wide linkage studies and genetic association studies based on candidate genes, but no genome-wide association studies, have been performed in migraine, leading to the discovery of several chromosomal loci. Underlying genes, however, have yet to be discovered. This also applies to studies in TTH and CH. Current research tackles methodological flaws in former studies by using large patient cohorts, multivariate statistical methods, and reducing clinical heterogeneity by the introduction of more refined methods of phenotyping, such as latent class analysis and trait component analysis. Also, gene expression profiles by detecting reliable biomarkers of disease will be helpful in the future. Results of large genome-wide association studies for migraine are expected soon. Future fields of headache research pertain to individual response and adverse effects to therapeutic drugs (pharmacogenetics), and the study of epigenetic factors.

Migraine is a prevalent disabling neurological disorder associated with a wide range of medical and psychiatric comorbidities. Population- and clinic-based studies suggest that psychiatric comorbidities, particularly mood and anxiety disorders, are more common among persons with chronic migraine than among those with episodic migraine. Additional studies suggest that psychiatric comorbidities may be a risk factor for migraine chronification (i.e., progression from episodic to chronic migraine). It is important to identify and appropriately treat comorbid psychiatric conditions in persons with migraine, as these conditions may contribute to increased migraine-related disability and impact, diminished health-related quality of life, and poor treatment outcomes. Here, we review the current literature on the rates of several psychiatric comorbidities, including depression, anxiety, and post-traumatic stress disorder, among persons with migraine in clinic- and population-based studies. We also review the link between physical, emotional, and substance abuse, psychiatric disorders, and migraine. Finally, we review the data on psychiatric risk factors for migraine chronification and explore theories and evidence underlying the comorbidity between migraine and these psychiatric disorders.

Background

To estimate utility values for different levels of migraine pain severity from a United Kingdom (UK) sample of migraineurs.

Methods

One hundred and six migraineurs completed the EQ-5D to evaluate their health status for mild, moderate and severe levels of migraine pain severity for a recent migraine attack, and for current health defined as health status within seven days post-migraine attack. Statistical tests were used to evaluate differences in mean utility scores by migraine severity.

Results

Utility scores for each health state were significantly different from 1.0 (no problems on any EQ-5D dimension) (p < 0.0001) and one another (p < 0.0001). The lowest mean utility, − 0.20 (95% confidence interval [CI]: -0.27 – -0.13), was for severe migraine pain. The smallest difference in mean utility was between mild and moderate migraine pain (0.13) and the largest difference in mean utility was between current health (without migraine) and severe migraine pain (1.07).

Conclusions

Results indicate that all levels of migraine pain are associated with significantly reduced utility values. As severity worsened, utility decreased and severe migraine pain was considered a health state worse than death. Results can be used in cost-utility models examining the relative economic value of therapeutic strategies for migraine in the UK.