A plain man's guide to the management of migraine.

Several family practitioners have told me that their hearts sink when a patient comes into the surgery complaining of migraine. I can sympathise with this feeling if the waiting room is full; it takes several minutes to establish a diagnosis, and a few more to find out the particular patient's triggering factors and then to explain and prescribe the appropriate treatment. The patient may therefore need to come another time when 10-15 minutes can be set aside for the consultation. I suggest some simple guidelines that may help with managing migraine. Making the right diagnosis The foremost objective is to make the correct diagnosis. In migraine an aura is not necessary, occurring in only 15-20% of patients. There are two varieties of migraine, migraine headache and migrainous neuralgia, which must be separated from two other common head pains-tension and muscle contraction headaches. Although tension and muscle contraction headaches are currently considered to be synonymous, I propose a separation as described below. DEFINITIONS Migraine-Episodic headache accompanied by visual or gastro-intestinal disturbances, or both, attacks lasting hours with total freedom between episodes-The visual symptoms occur as an aura before or photophobia during the headache phase. The Based on a talk to family practitioners held at St Bartholomew's Hospital Medical College, 18 November 1981. alimentary symptoms consist of nausea and vomiting. If there are no visual but only gastrointestinal disturbances then vomiting must feature in some attacks. Migrainous neuralgia-Episodic attacks of pain behind one (the same) eye, which becomes red and waters, the nostril on the ipsilateral side becoming blocked or discharging a watery fluid. Attacks last 20-120 minutes, occur daily for several weeks (hence the term cluster headaches), often wakening the patient in the early morning hours-sometimes so regularly as to merit the term "alarm-clock headaches." During a cluster period alcohol provokes attacks. Tension headache-A continuous symmetrical headache often described as a pressure, awareness, or discomfort at the vertex, forehead, or occiput, or a coronal distribution or all over the head, not associated with visual or gastrointestinal symptoms. The ache lasts hours, often throughout the waking period, rarely interferes with daily activities, and is unaffected by analgesics. Muscle contraction headache-A painful tender muscle, or a muscle spasm adjacent to a painful site-for example, cervical spondylosis or a temporomandibular joint. Treating the underlying cause gives partial or complete relief of symptoms. Multiple diagnoses-Migraine is common (5-7% of the population) and clearly not all …