A Response from the Authors


  • Richard B. Lipton MD,

  • Walter F. Stewart MD

We thank Dr. Tepper for selecting our article, reporting results from the American Migraine Study-1 (AMS-1) as one of his favorites over the past 50 years.1 As the very first article we wrote together, the manuscript launched an enduring collaboration and a lifelong friendship.

When the article was published, a JAMA press release highlighted low household income as a major risk factor for migraine. The CNN story about the study was illustrated with a video image of homeless men in tattered clothing, huddling around the burning contents of a garbage can, warming their hands on the leaping flames. In that moment, our hopes for improving the recognition of migraine as a legitimate public health problem were replaced by the fear that we had inadvertently stigmatized the illness, the homeless, or both.

Despite that inauspicious beginning, the AMS-1 was the foundation for research themes that continue to this day. Recognition of the disabling impact of migraine led us to develop measures of functional impairment, first the Headache Impact Questionnaire and then the Migraine Disability Assessment Scale.2-5 Knowing that the prevalence of migraine peaks between the ages of 25 and 55 years motivated the measurement of work impact of migraine, as well as other pain disorders.6-8 The underdiagnosed and undertreatment of migraine led us to focus on strategies to improve diagnosis, including public and clinician education as well as diagnostic screening tools such as ID-migraine.9-12

The AMS-1 taught us that most migraine sufferers who seek medical care do so in primary care settings, revealing the importance of engaging primary care clinicians in efforts to improve headache outcomes. Recognizing migraine's broad spectrum of severity motivated the notion that treatment should be matched to illness severity13-14 and the demonstration that stratified care, based on disability assessment, produces better outcomes than step-care.15

The AMS-1 provided a report card on headache management in 1989 and set the stage for reevaluations 10 and 15 years later.16-18 This series of studies reveals how far we have come, with ever-increasing rates of diagnosis and appropriate treatment, and how far we have to go. As the American Headache Society enters the second half of its first century, we look forward to further developments in headache science and their rapid translation into clinical practice.