Update on Headache

Thomas N. Ward, MD

A. Laine Green, MD

Headache is common and serious. It is in the top 10 of presenting complaints by patients to a primary care provider. It is also easily the most common presenting complaint to a general neurologist. Headache is also commonly encountered by neurosurgeons, otorhinolaryngologists, pain specialists, and specialists in physical medicine and rehabilitation. Due to its commonality, it results in significant disability for patients. It strains our healthcare systems both in direct and indirect costs.

As we reflect on medical education (using the experiences of Dr. Green as an example), we find it interesting and ironic that in 4 years of medical school training there was one 1-hour lecture on all headache disorders. During neurology specialty training, there were four 1-hour lectures dedicated to the same topic. We often receive more education and lectures on other disease states that will rarely, if ever, be seen in clinical practice. Thus, it was delightful that we were asked to guest edit this issue of Seminars in Neurology. Increasing awareness and education on headache diseases is professionally and personally rewarding.

It goes without saying that the proper treatment of a disease starts with the correct diagnosis. The International Classification of Headache Disorders, now in its 3rd iteration, is an excellent framework for reaching the correct diagnosis. It should not replace sound clinical judgment, but it keeps us all speaking the same language. It is of paramount importance for current and ongoing research trials.

Those who diagnose and treat headache disease are always concerned there is a secondary process that has commandeered the system and is manifesting as migraine or another primary headache disorder. Consideration for other disease states or disorders is a valuable cognitive endeavor. Growing recognition into one specific etiology, posttraumatic headache, is of mounting importance. It has special implications for our children involved in sports and for military personnel. Even though it often manifests as a migraine phenotype, research into the functional imaging networks involved suggests it is a unique entity.

We are currently reaping the benefits of decades of research into the pathophysiology of headache disorders. Our understanding, especially with respect to migraine and the trigeminal autonomic cephalgias, has grown exponentially. We are also starting to see the compounding benefits of past and current advancements of pathophysiology, identifying important therapeutic targets.

Children are not simply small adults. Special consideration for diagnosis, and especially treatment, is of paramount importance in this population. Proper multidisciplinary support throughout their developing and educational years will set them up for future successes.

Unfortunately, no cure for primary headache disorders currently exists. These disorders often disproportionally affect individuals at the height of their educational careers and chosen occupations. Thus, effective management is crucial. A patient-centered approach is the preferred path. A combination of lifestyle modifications and nonpharmacological, acute, and reduction-based (prevention) treatments is the basis for success. This update focuses on migraine treatments, given it is the most common headache disorder we will encounter. Ultimately there will be some in whom treatments will fail or more importantly the treatments fail our patients. Thus, persistence will be required.

Some patients will be challenging due to their refractory nature to treatment approaches. Identifying contributing factors may be helpful in these individuals. Medication overuse headache, new daily persistent headache, and persistent refractory headache attributed to SARS-CoV-2 infection (secondary to COVID-19) warrant special considerations.

We hope you enjoy this collection of articles and hope it gives you additional insight (or reinforces your current knowledge) into the diagnosis and treatment of headache disorders. We would sincerely like to thank and acknowledge the assistance of Dr. David Greer (editor-in-chief) and Dr. Ariane Lewis (deputy editor) for their support, advice, and leadership in the development of this Update on Headache.

Thomas N. Ward, MD, and A. Laine Green, MD, Guest Editors

Publication History

Article published online:
02 November 2022