Clinical Review

Recent advances in the diagnosis and management of migraine

BMJ 2006; 332 doi: http://dx.doi.org/10.1136/bmj.332.7532.25 (Published 05 January 2006) Cite this as: BMJ 2006;332:25
  1. Peter J Goadsby, professor of clinical neurology (peterg@ion.ucl.ac.uk)1
  1. 1 Headache Group, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG
  • Accepted 28 November 2005

Introduction

The World Health Organization considers that severe migraine can be as disabling as quadriplegia.1 The disorder affects as many of 15% of adults in North America and Western Europe and is probably one of the commonest reasons for patients to see their doctors. Traditionally, headache is given little time in medical teaching, but headache science is advancing rapidly, fuelled by developments in treatment and neuroscience, and there is a sense of excitement perhaps unrivalled in neurology. Many recent advances have particular relevance to clinical practice in terms of both diagnosis and management; I will highlight these. Interested readers should see recent monographs listed in the Further reading box for more detailed accounts of the management of headache disorders.

Methods

I based my selection of topics for this review on clinical themes that arise from referrals to the Headache Group at the National Hospital for Neurology and Neurosurgery. Thus the primary driver for the review is clinical practice. Information has come particularly from my reading large sections of a major reference work on headache as an editor (see Further reading box), and from the major headache journals, Cephalalgia and Headache, which I hand searched for the past decade. These sources are supplemented by PubMed searches and information from the most recent congress of the International Headache Society in Kyoto (10-12 October 2005). Some aspects of this review are based on a recent publication.2

Headache classification—improving and simplifying the diagnosis of migraine

The development and promulgation of the International Headache Society's diagnostic criteria in 1988 was an important milestone, giving clear guidance and having widespread acceptance. Migraine was defined by the component clinical parts of an attack so that the most important tool for the clinician was a good history (box 1). The second edition of the international classification of headache disorders (ICHD-II)3 has seen fine tuning …

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