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  1. Top of page
  2. Abstract
  3. The 1950s and 1960s: Legitimizing Headache
  4. The 1970s: The Era of the Headache Clinic
  5. The 1980s: A Headache by Any Other Name
  6. The 1990s: The Decade of the Triptans
  7. The 2000s, So Far: Credibility and Activism

As the American Headache Society approaches its 50th anniversary, it seems worthwhile to step back and survey the many changes in the headache field since the 1950s. Many, perhaps most, of the trends, ideas, and changes we review in this article cannot easily be assigned to a particular decade but we have nonetheless chosen a by-the-decade format because it is a familiar and useful way of understanding history. Our focus is on events in the United States and the American Headache Society; space and the need to limit the scope of the article preclude a full description of the many parallel and influential trends, personalities, and ideas in other parts of the world or in other professional organizations. The authors hope you will find this summary of American Headache Medicine in the last half of the 20th and the beginning of the 21st centuries entertaining and educational.


The 1950s and 1960s: Legitimizing Headache

  1. Top of page
  2. Abstract
  3. The 1950s and 1960s: Legitimizing Headache
  4. The 1970s: The Era of the Headache Clinic
  5. The 1980s: A Headache by Any Other Name
  6. The 1990s: The Decade of the Triptans
  7. The 2000s, So Far: Credibility and Activism

Terminology By mid-century, the simple word “migraine” had given way to “vascular headache of the migraine type.” Histamine or cluster headache was thought to be a variant of migraine, but Dr. Bayard Horton described it as a distinct entity. What we now call tension-type headaches were thought to be due to contractions of scalp or neck musculature, hence the term “muscle contraction headache.” A major advance in establishing criteria for headaches was the 1962 publication of “Classification of Headache” by a committee of the National Institute of Neurological Diseases and Blindness (see Box). The terms “vascular headache of the migraine type” and “muscle contraction headache” were preserved, but the criteria were far from precise. Both types of headache, according to the classification, “. . . widely varied in intensity, frequency, and duration” and ambiguous adjectives such as “commonly,”“sometimes,” and “often” were used to note qualities and associated features. Vascular headaches of the migraine type were divided into “classical migraine” (migraine with aura) and “common migraine.” Also during these decades, ER Bickerstaff described “basilar artery migraine” and Bo Bille reported characteristics of migraine in children. Migraine equivalents were described. Some found frequent electroencephalographic (EEG) abnormalities in migraine patients and used the term “dysrhythmic migraine.”

Pathophysiology Pathophysiological concepts in the decades of the 1950s and 1960s were carryovers from the first half of the century. The aura of migraine was thought to be due to vasoconstriction and the headache was attributed to vasodilation. In the 1950s, researchers had come to realize that vasodilation per se would not cause headache. Rather, there had to be additional nociceptive phenomena around the blood vessels. It was thought that the vessels were excessively permeable and that polypeptides labeled “neurokinins” were released causing a sterile inflammatory reaction. In 1958, Milner called attention to “correspondence between the scotomas of migraine and spreading depression (of cortical neurons) of Leao.” The role of allergies as cause of migraine was frequently debated, but even then the consensus was that allergies may trigger the attack but were not a basic cause. “Sinus headache” was sometimes invoked, but in a study of 460 headache patients, only 7% were found to have sinusitis.

Although scalp and muscle contraction was thought to be the cause of headaches, which adopted that name, some studies found that increasing muscle contraction (eg, by electrical stimulation) did not increase the headache.

Psychological disorders were thought to be a major or primary etiologic factor in both migraine and muscle contraction headaches. Common statements were as follows: “. . . headache is a psychosomatic expression . . . of tension or anxiety.”“. . . scotomas of migraine are related to previous visual psychological trauma, which are [sic] repressed.” A psychoanalyst stated that “. . . migraine sufferers are orally fixated . . . and anal sadism was strongly developed in these patients . . .”“Psychological factors are associated with the vast majority of tension/muscular headache. These patients demonstrated aggression, hostility, and intense resentment against members of their family.”

Although most agreed that moderate to severe psychoneurotic traits were present in most patients, many admitted that “not all patients with migraine are compulsive, perfectionistic, or rigid.” In the late 1950s and early 1960s, Federigo Sicuteri and coworkers found evidence of changes in serotonin metabolism during migraine. They found an increased release of the major serotonin metabolite 5-hydroxyindolacetic acid. This concept was supported by the effectiveness of methysergide (a serotonin antagonist) as a prophylactic agent. Blood flow in scalp musculature was found to increase during muscle contraction headache, but the finding did not shed much light on its underlying mechanism. Some drugs were recognized as causing headaches, particularly the monoamine oxidase inhibitors and oral contraceptives.

Treatment Ergotamine tartrate, first introduced in the 1920s, continued to be the drug of choice for the acute attack of migraine. In the 1950s, the agent was administered by oral and rectal routes, and in the 1960s, sublingual and inhalation routes were added. Oral analgesics and intravenous dihydroergotamine were also used for the acute attack. The combination of aspirin, caffeine, and butalbital (Fiorinal) became popular for the acute attack of headache. Hydergine (dihydroergotoxine mesylate) was developed for migraine prophylaxis. Many other agents, including hormones and steroids, were recommended for acute and prophylactic therapy in the 1950s. Arnold Friedman, TJ VonStorch, and HH Merritt evaluated a thousand patients with migraine and a thousand patients with muscle contraction headache and found “. . . psychotherapy to be the best method of preventing an attack.” But by the end of the 1950s, psychotherapy was something to be considered rather than a major therapeutic modality.

In the 1950s, it was noted that frequent use of ergots may lead to an increased frequency of migraine via a rebound mechanism. But, the concept of medication overuse headache causing episodic headache to evolve into daily headache had not yet been appreciated. By the end of the 1950s, Sicuteri and associates had introduced methysergide, and it became the prophylactic treatment of choice for migraines. By the end of the 1950s, “tranquilizers” and monoamine oxidase inhibitors were being used for so-called muscle contraction headache.

In the 1960s, although methysergide was found to be of definite value in the prevention of migraine, retroperitoneal and intrathoracic fibrosis was reported in a small number of cases and its use declined. Still, methysergide had a lasting effect on ideas about headache, as the following account by Neil Raskin illustrates:

I was still in training when methysergide was introduced in 1960. It was quite astonishing how this drug changed physicians’ thinking about the nature of migraine. Prior to that time, and all through the 40s and 50s, migraine was thought to be predominantly psychosomatic. I think back to all those patients that I had sent to psychiatric consultants who came back to me with ‘no psychopathology;’ the common response was that the psychiatrists were not sophisticated enough. Suddenly, patients could take a few tablets of methysergide and within a week they were headache-free. No change in their internal milieu. Cured. Unfortunately, there were some problems with methysergide, but this drug's ability to antagonize certain actions of serotonin peripherally abruptly transformed migraine from a psychosocial problem into a scientific one. Whether or not methysergide has turned out to be the public health answer to migraine is less important than the fact that it was the first of what I term ‘stabilizing drugs.’ It was the first of the stabilizers that could actually affect the mechanism in such a way that symptoms did not reappear. It didn't simply suppress symptoms but actually reset the mechanism so that patients could go about their lives and forget about headaches. This was an extremely important concept that changed how physicians thought about migraine.

Also in that decade, the antiepileptic drugs came into use for headache, particularly in patients who had abnormal EEGs (dysrhythmic migraine). Cyproheptadine was introduced for migraine prophylaxis. The combination of ergotamine, belladonna alkaloids, and phenobarbital (Bellergal) was found to be effective and continued to be used into the 21st century. Amobarbital was recommended for some acute attacks of migraine. The tricyclic agents, amitriptyline and imipramine, were found to be more effective than placebo for prophylaxis. Other therapeutic modalities included ligation of the superficial temporal artery, histamine desensitization, gonadotropin, and diverse drug combinations. For muscle contraction headaches, new analgesics, sedatives, and tranquilizers were added to the pharmacopeia.

Societies, journals, and clinics A major event in legitimizing headache as a serious health problem occurred on June 8, 1959 when a small group of physicians attending the American Medical Society formed the American Association for the Study of Headache (AASH), now the American Headache Society (AHS). At the first meeting of AASH, the name of the organization was debated. The word “headache” was thought by some “too common,” and the word “cephalalgia” was suggested instead. But, as one of the members said, “What is wrong with speaking English?” The fledgling AASH held its second meeting in 1960 and began publishing a journal, Headache, in 1961. The Harold G. Wolff award was established by AASH in 1966.

Specialized headache clinics were extremely rare during this time. Arnold Friedman, H. Houston Merritt, and Charles Brenner founded the first, Montefiore Headache Unit in New York, in 1945. Dr. Friedman continued as the sole director. In 1964, Dr. Seymour Diamond established the Diamond Headache Clinic in Chicago. Dr. Diamond was a driving force in AASH for many years.

The bottom line The events of the 1950s and 1960s helped establish headache as a legitimate field of medicine by increasing biological and epidemiological research, creating a more extensive classification of diagnosis and criteria for headaches, and increasing the education of physicians and the lay public with leadership from the newly formed AASH.

The 1970s: The Era of the Headache Clinic

  1. Top of page
  2. Abstract
  3. The 1950s and 1960s: Legitimizing Headache
  4. The 1970s: The Era of the Headache Clinic
  5. The 1980s: A Headache by Any Other Name
  6. The 1990s: The Decade of the Triptans
  7. The 2000s, So Far: Credibility and Activism

Terminology In 1970, the World Federation of Neurology Research Group on Migraine and Headache published a definition of migraine as “a familial disorder characterized by recurrent attacks of headache that vary widely in intensity, frequency, and duration. The attacks are commonly unilateral, and are associated with nausea, anorexia, and occasionally vomiting. In some cases they are preceded by, or associated with, neurologic and mood disturbances.”

Dissatisfaction with headache criteria persisted, however. WE Waters, writing in the International Journal of Epidemiology in 1973, discussed the “epidemiologic enigma of migraine” and noted that a study attempting to identify the salient features of migraine failed to show that the studied features (unilaterality, prodrome, and nausea) “occurred in the same individual, during the twelve-month period, more frequently than would be expected on the basis of chance concurrences, depending simply on the separate prevalences of each feature. These epidemiological findings suggest the need for a more critical approach to the problems of defining migraine.” This challenge would not be taken up for more than a decade. In the meantime, “common” and “classic” migraine reigned supreme.

Pathophysiology During the 1970s, the “vascular theory of migraine,” articulated by Harold Wolff, was still held to explain migraine: “The neurological symptoms are due to cerebral vasospasms and the headache is caused by a subsequent reactive hyperaemia with dilatation of the arteries.”

Treatment Research on behavioral treatment of headache, especially biofeedback, blossomed, and interest grew in multidisciplinary approaches to the complex problem of chronic, disabling headache. Many of the pharmacologic treatments still in use for headache treatment were developed and tested in the 1970s. The recollections of Dr. Seymour Diamond make this clear:

After reading the article by Sjaastad and Dale in Headache in 1974 about chronic paroxysmal hemicrania (CPH), I started using indomethacin in those headache patients experiencing a form of exertional or orgasmic headache. Jose Medina and I presented our findings on benign exertional headache at the AASH meeting in Boston in June, 1979. In a personal communication with Doctor Sjaastad, I informed him that we could demonstrate four cases of CPH which were treated successfully with indomethacin. Upon Doctor Sjaastad's request, I arranged for him to visit our Clinic to examine these four patients as well as other cases of indomethacin-responsive headaches, such as exertional headaches and a new syndrome that we called “Cluster Headache Variant.”

. . . we started to use propranolol in the treatment of migraine following publication of the article by Weber and Reinmuth (1971) which reported on the coincidental efficacy of this drug in migraine patients. Many of our patients with migraine, with or without aura, responded positively to propranolol treatment. Because of these results, I contacted Doctor Rudolph Widemark of Ayerst Laboratories, the manufacturers of propranolol. Doctor Widemark visited me in Chicago and advised that Ayerst was then involved in several studies on the use of propranolol in migraine prevention, which were located at various academic institutions. Although prestigious, these institutions did not have the organization or caseload to thoroughly conduct FDA-acceptable protocols. I suggested studies at our clinic as well as the headache clinic at Faulkner Hospital in Boston, which was headed by Doctor John Graham. Propranolol received approval from the FDA for the indication of migraine prophylaxis based on the results of two studies involving 104 patients. Doctor Jose Medina and I reported on 62 evaluable patients (Diamond and Medina, 1976), and an unpublished report of John Graham was on 42 cases treated with propranolol. It is amazing that to receive approval from the FDA during our current climate of regulation, evidence must be presented from double-blind studies which enroll over 1000 patients.

An aside to the propranolol story, which you may find interesting, is my appearance before the FDA panel of physician reviewers in the spring of 1976. This panel consisted of various neurologists from prestigious institutions but no recognized headache specialists. Of the 104 patients cited in the research data, about 20 percent were diagnosed with migraine with aura. Propranolol only received approval for the indication of treatment of migraine without aura. I did not debate the issue with the panel as I thought it may negatively impact on the approval of the drug and any further discussion may grow contentious. This limitation in the indication did not affect the popularity of the drug in migraine prophylaxis.

Societies, journals, and clinics The American Association for the Study of Headache held its first winter update course on headache in Scottsdale, Arizona. This meeting, traditionally held at the Camelback Hotel, remains a fixture of the organization's educational program to this day.

Heavily influenced by Marcia Wilkinson and early pioneers at Montefiore and Chicago, European and US headache practitioners developed and expanded specialized headache clinics and centers. In a 1979 article describing the establishment of the Copenhagen Acute Headache Clinic, Olesen and colleagues acknowledged that they were “inspired by the British example.”

Dr. Seymour Diamond established the National Headache Foundation in the 1970s. The organization has remained a force in the American headache field since that time and is particularly well known for its wide network of patient support groups.

The bottom line A significant phenomenon of the 1970s, and one that has had a lasting influence on the field to this day, was the proliferation of specialized headache treatment centers or units. Interest in the pharmacologic treatment of headache grew, as did the expertise of American headache practitioners in the conduct of clinical trials and the application of scientific methods to headache investigation.

The 1980s: A Headache by Any Other Name

  1. Top of page
  2. Abstract
  3. The 1950s and 1960s: Legitimizing Headache
  4. The 1970s: The Era of the Headache Clinic
  5. The 1980s: A Headache by Any Other Name
  6. The 1990s: The Decade of the Triptans
  7. The 2000s, So Far: Credibility and Activism

Terminology Use of the Ad Hoc Committee classification continued in the early part of this decade but proved unsatisfactory for a number of reasons. The frequently used terms “tension” or “muscle contraction” headache, for example, implied etiologies that seemed increasingly dubious. The trials necessary to test potential treatments for various headache disorders likewise exposed the weaknesses of a classification system that, according to the epidemiologist Waters, was based on “just descriptions rather than explicit definitions.”

In 1988, Cephalalgia published the first version of the International Classification of Headache Disorders (ICHD), entitled “Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain.” Work had begun on the document 3 years before. According to the Preface, the project had involved 12 subcommittees, several public meetings, and a large amount of volunteer labor by committee members. In the Introduction, the authors wrote that “The primary use is for research, but over the course of years it will probably influence the way we diagnose patients in our daily work.” They pre-emptively warned readers, “please do not be overwhelmed” and offered the reassuring comment that the classification was “not supposed to be learned by heart.” Noting the many difficulties in classifying a group of disorders whose pathophysiology varied and that were poorly understood, the authors of this new Classification pointed out that “it has not been possible to classify patients, only to classify headaches.” Established terms such as “common” and “classic” migraine proved stubbornly durable, but gradually gave way to the more modern and descriptive terminology of “migraine without aura” and “migraine with aura.”

Pathophysiology In the early 1980s, Jes Olesen published his observations that in migraine attacks triggered by carotid angiography, reductions in cerebral blood flow demonstrated by xenon blood flow techniques were not sufficient to cause ischemia. An especially important finding was that blood flow changes did not respect large arterial territories but instead spread slowly at a rate consistent with that observed for the cortical phenomenon then known as “spreading depression of Leao.” Milner had earlier proposed this as the explanation for migraine aura, but it was not until work by Lauritzen during the 1980s that strong evidence for the link emerged.

Work by Michael Moskowitz showed plasma extravasation from cerebral vessels with stimulation of the trigeminal nerve in animals, and ideas about the underlying explanation for migraine expanded, with frequent reference to migraine as a trigeminovascular, rather than a simple vascular, disorder. A number of headache drugs were shown to block plasma protein extravasation and ideas about such sterile inflammation as a cause of pain developed.

Less evidence-based explanations were also advanced to explain various clinical phenomena. The author of a Headache article on “Opioids, Pregnancy and the Disappearance of Headache” reported “Women that have gone through this experience agree that it is one of the happiest periods in their lives . . .” He suggested that this “so-called ‘state of bliss’ ” and the disappearance of headache might be due to placental opioid-like substances such as endorphins.

Some diagnostic entities appeared in the literature that have since disappeared. A study of “Salt-induced migraine” reported in Headache remains interesting because it demonstrates an early use of placebo in a headache study. Gelatin or sodium chloride capsules were given to 25 migraine sufferers and 24 nonmigraineurs. In total, 14/15 migraineurs who got salt developed headache compared with 1/10 who received gelatin capsules. In contrast, 3/24 controls given salt and 0/24 given gelatin got a headache the next day.

Treatment In the United States, nonspecific medications were in common use for acute treatment of headache disorders. Many contained barbiturates. Perusal of Headache issues through the decade reveals numerous advertisements for barbiturate-containing drugs including Phrenelin, Empirin with codeine, and Fiorinal. Ergots were also used, and an advertisement for the branded ergotamine product Wigraine admonished readers that it should be “taken at the first symptom . . . to halt throbbing head pain before it takes hold” . . . “disintegrates 7-70 times faster than other migraine preparations” due to “a patented microgranulation process” that “bursts” the tablet apart . . .” To doctors who have lived through the recent onslaught of pharmaceutical advertisements for more modern headache treatments, these claims will sound familiar although the drugs touted have changed. In 1984, an event occurred that was destined to have far-reaching consequences for headache and headache sufferers in the next decade. Scientists at Glaxo synthesized GR 43175, a 1B/1D serotonin agonist later named sumatriptan.

The 1980s saw the serendipitious discovery by Karl Ekbom that lithium was effective in preventing cluster headache, and indomethacin was increasingly used for the newly recognized indomethacin-responsive headache syndromes. Lee Kudrow, a cluster headache sufferer himself, popularized the use of oxygen to abort cluster headache attacks. Much fundamental research on biofeedback also occurred during this decade. Headache published a description of a 5-day training program for patients run by the famed Menninger clinic in Kansas, and studies by Roy Mathew and others were published, including cerebrovascular researchers Fumihiko Sakai and John Stirling Meyer, evaluating cerebral blood flow changes with biofeedback.

Calcium antagonists and valproate were tested and entered clinical practice in the 1980s.

Dr. Ninan Mathew recounts the events leading to Food and Drug Administration (FDA) approval of valproate for migraine prophylaxis:

The interest in valproate developed both in Europe and in the U.S. more or less simultaneously around 1987-1988. There were many reasons for it. One, of course, was the fact that there were some data supporting the idea that there is cortical hyperexcitability in migraine. I had edited a Neurologic Clinics in 1990 in which Michael Welch wrote a chapter detailing the evidence in favor of cortical hyperexcitability in migraine. So, that concept was going on in 1987, 1988 and 1989, which led to the trial of valproate initially. Apart from the cortical hyperexcitability theory, one of the other key observations was that valproate, a GABA mimetic agent, acts on GABA receptors in the dorsal raphe nuclei resulting in decreased firing rate of serotonergic cells. This basic observation by Nishikawa, published in Pain Research in 1985, was the other major supporting observation which led to the use of valproate. Along with me, Neil Raskin also started using valproate in patients from 1988. The first paper on valproate (an open-labeled study) was published by Sorensen in Acta Neurologica Scandinavia in 1988. In 1991, I published an open-labeled trial of valproate in persistent chronic daily headache. (Headache 1991;31:71-74)

Abbott Pharmaceuticals, which owned valproate, was not interested to pursue the development of valproate as a prophylactic agent in migraine. It was mainly due to my constant pressure on them which led them to agree to a double-blind placebo controlled multicenter study of valproate in prophylactic treatment. The studies were positive and the first pivotal paper was published in Archives of Neurology in 1995 (Mathew, et al). In addition to our paper, there were confirming reports from Denmark (Jensen, et al) and also from Kuritzky and later, from Klapper. The positive studies led to approval of valproate. The use of valproate in migraine was not because of its comorbidity with epilepsy.

Societies, journals, and clinics In 1980, AASH had 450 members and held its annual meeting June 20-22 in San Francisco. By the close of the decade, AASH membership cost $100 annually and the journal was published 10 times a year. Readers were urged to subscribe to Headache, “now in its 29th year” at a cost of $55.00 if they did not wish to join and get the journal as a membership benefit.

The January 1980 issue of Headache opened with instructions for authors: “An original typescript and two high quality copies of all manuscripts . . . typed double-spaced on 22 × 28 cm (8½ × 11 inch), heavy-duty white bond paper . . .” Prospective authors were to send the result “. . . by first-class mail to the Editor,” who was then Donald Dalessio. His editorial board included James Couch, James Dexter, John Edmeads, C. Miller Fisher, John Graham, Lee Kudrow, Ninan Mathew, Jon Stirling Meyer, Neil Raskin, Joseph Sargent, Federico Sicuteri, and Dewey Ziegler.

The first issue of Headache published in the 1980s included a transcript of “Headache Rounds” held at the Graham Headache Center in Boston. The cases of 2 patients with headache were presented; they were being seen in weekly psychotherapy and the treatment discussion centered on psychological issues. Other articles in this issue reviewed matters of patient compliance, psychogenic headache, and a study which found that headache questionnaires were reliable, but not as valid as daily recordings of headache.

The last Headache issue of the decade was published in 1989. It contained 8 research articles, and the familiar Midrin advertisement –“interrupts migraine headache at the first sign”– was firmly established on the back cover. (A Midrin advertisement graced the back cover of the journal for over 2 decades: it debuted in the January 1981 issue of the journal, supplanting an advertisement for Esgic. The last back cover Midrin advertisement would not appear until the July/August 2001 issue, after which the back cover began to feature triptan advertisements.) Advertising copy within the journal during the 1980s touted Inderal LA –“the one to start with to prevent common migraine”– and Advil, along with Nimotop and Phrenelin.

In 1989, the editor of Headache was John Edmeads, with an editorial board consisting of Frank Andrasik, James Couch, Don Dalessio, James Dexter, Seymour Diamond, C. Miller Fisher, Lee Kudrow, Ninan Mathew, John S. Meyer, Neil Raskin, Joseph Sargent, and Seymour Solomon. The front cover design of the journal did not change during this decade.

In 1980, the International Headache Society was formed. It published the first issue of its journal, Cephalalgia, in 1981.

The bottom line The publication of the ICHD was arguably the most important event of the 1980s. Its far-reaching consequences for headache research and practice became apparent during the following decade, and it continues to wield enormous influence on thought and practice in the headache field. Another event in this decade, however, competed with ICHD as a contender for milestone status, at least as measured by the events of the next decade. This was the synthesis of sumatriptan, which along with its successor drugs dominated the attention of headache practitioners and patients in the 1990s.

The 1990s: The Decade of the Triptans

  1. Top of page
  2. Abstract
  3. The 1950s and 1960s: Legitimizing Headache
  4. The 1970s: The Era of the Headache Clinic
  5. The 1980s: A Headache by Any Other Name
  6. The 1990s: The Decade of the Triptans
  7. The 2000s, So Far: Credibility and Activism

Terminology The terminology of ICHD gradually took root in the daily conversation and writing of headache specialists, though the terms “common” and “classic” migraine continued in sporadic use. A revision of ICHD had been planned for the mid-1990s, but the task proved enormous. The rapid pace of research findings, some of which would need to be taken into account in any updated classification system, was one factor in the delay.

Pathophysiology During this decade, several pharmacologic compounds that had been predicted to work for migraine failed in clinical trials, including substance P inhibitors and neurokinin-1 antagonists. These drugs successfully blocked plasma protein extravasation after trigeminal ganglion stimulation, but did not abort migraine attacks in humans. In the latter part of this decade, work by American scientist Rami Burstein and colleagues reintroduced ideas about the influence of peripheral and central sensitization and its role in individual migraine attacks. Speculation grew that it might underlie the clinical progression of headache observed to occur in some patients.

Treatment The 1990s were defined by the advent of the triptans. For a short time after its introduction, injectable sumatriptan had the US triptan market to itself. Oral sumatriptan and 6 other oral triptans followed on its heels, however, and the “triptan wars” raged throughout the decade.

Work on valproate had begun during the 1980s, and as it turned out, this was the single prophylactic drug that gained FDA approval for migraine prophylaxis during the 1990s. However, Ninan Mathew recalls that during this decade “Other prophylactic agents including gabapentin and later, topiramate were initially tried as open-labeled trials, which were positive. I remember our first open-labeled trial of gabapentin published in 1996 as an abstract in Neurology. That report created some interest with Pfizer and they agreed to do a double-blind placebo controlled trial, which was positive and was published in 2001.” (Mathew, et al)

Societies, journals, and clinics In 1996, all past issues of Headache and Cephalalgia were put on a searchable CD-ROM. The number of personal and workplace computers had by now reached a tipping point. The era of computerized manuscript preparation, submission, and publication began in earnest, and almost overnight conventional slides disappeared as the “disruptive technology” of Powerpoint and computerized projection took over. Doctors who had once toted round carousels of slides now carried rectangular computers. Struggles with incompatible computer systems and LCD projectors replaced the smell of burning slides that had slipped into the innards of a projector. In 1997, AASH and its patient organization, the American Council for Headache Education, launched a web site.

In 1999, AAHS president Dr. James Couch initiated a series of meetings to develop a strategic plan for the organization that has guided its activities ever since.

The bottom line It is difficult to overestimate the effect of the triptans on the events of this decade. The influx of pharmaceutical dollars and interest did much to stimulate research and raise credibility, but some worried that the headache research agenda was too influenced by the goals of industry.

The 2000s, So Far: Credibility and Activism

  1. Top of page
  2. Abstract
  3. The 1950s and 1960s: Legitimizing Headache
  4. The 1970s: The Era of the Headache Clinic
  5. The 1980s: A Headache by Any Other Name
  6. The 1990s: The Decade of the Triptans
  7. The 2000s, So Far: Credibility and Activism

Terminology It is now rare to hear such terms as muscle contraction headache or common migraine, unless it is in the context of a historical lecture. Controversy continues, however, over the terms that should be used to describe certain common clinical syndromes. Two difficult problems are how to classify the syndrome of frequent or chronic daily or near-daily headache that evolves from episodic headache disorders, and how to classify headaches associated with medication use. In the wake of United Council for Neurologic Subspecialties certification and accreditation pathways, the term “Headache Medicine” is increasingly used.

Pathophysiology This decade has seen consolidation of the view that migraine is a problem that starts in the brain. The unifying hypothesis of migraine as a “sensory attentional problem” due to dyshabituation and changes in cortical synchronization has been advanced. The link between aura and migraine remains poorly understood, with controversy about whether cortical spreading depression occurs in some, most, or all attacks of migraine. Imaging studies during this decade confirm thalamic activation contralateral to headache pain in migraine, cluster headache, and short lasting unilateral neuralgiform headaches with conjunctival tearing. Interest has grown during this decade in the medical implications of migraine. Evidence emerged of the association of migraine with stroke, cardiovascular disease and pre-eclampsia, and the influence of obesity on its progression.

Treatment The year 2000 saw the publication of Headache Consortium treatment guidelines, developed in collaboration with members from a variety of groups including AHS, National Headache Foundation, American Academy of Neurology, and American College of Physicians. These evidence-based treatment recommendations reflected several years of work on evidence synthesis and grading, and proved influential. No new acute care drugs emerged to challenge the ascendancy of triptans during this decade, but as of this writing, calcitoruin gene-related peptide inhibitors seem likely to enter practice at some point. Sumatriptan is about to lose patent protection, but the implications of this for patients remain uncertain.

A growing challenge to headache treatment during this decade has been the corporatization and bureaucratization of medical practice in the US. Decision-making has moved steadily away from the physician and patient to administrators. This has limited the autonomy of physicians to prescribe certain headache treatments and the ability of patients to access them. The zero-sum game of cost controls has proved especially harmful to patients with chronic, difficult-to-treat headache problems. The shortage of headache-interested physicians and healthcare workers in the US is a growing problem; this will be a serious barrier to translating research advances into clinical practice.

Societies, journals, and clinics In 2000, AASH changed its name to the AHS. The Neurology Ambassador Program developed by the AHS brought a focused, one day, evidence-based program on headache to thousands of US neurologists. Based on its success, AHS developed a similar program, Brainstorm, for primary care physicians. A particularly important AHS educational endeavor during this decade was the development of an educational program on headache aimed at neurology residents. The program used a state-of-the-art interactive computer platform with individual feedback on performance to residents and residency directors, and met American Council for Granduate Medical Education core competency requirements.

The AHS Strategic Plan emphasized the development of special interest sections within the organization. Within a section, members with a common interest in a particular aspect of headache could meet and collaborate on research and educational projects. The number of special interest sections grew throughout the decade, and their elected representative sits on the AHS Board of Directors. The sections began to compete for small research grants and to organize educational symposia that could be presented during the course of AHS scientific and educational meetings.

In 2001, the AHS and the International Headache Society jointly hosted the International Headache Congress (IHC) in New York City. The 2009 IHC meeting is scheduled to take place in Philadelphia.

Several other important events occurred in the 2000s. In 2006, the United Council for Neurologic Subspecialties recognized Headache Medicine as a subspecialty of neurology, and developed pathways for certification of practitioners and accreditation of fellowship programs. Frustration with historically low levels of National Institutes of Health funding for headache research in the US led to the formation of the Alliance for Headache Disorders Advocacy. In the fall of 2007, headache practitioners from a number of states converged on Washington, DC to visit their Congressional representatives and urge attention to headache.

The bottom line The pace of scientific progress in headache has quickened, and the development of certification and accreditation in Headache Medicine seems certain to increase the academic stature of the field. At the same time, cost constraints on medical care, limited funding for headache research, and a headache workforce shortage loom as significant problems.

Members of the 1962 Ad Hoc Committee on Classification of the National Institute of Neurologic Disease and Blindness

  • Dr. Arnold P. Friedman (chairman)

  • Knox H. Finley

  • John R. Graham

  • E. Charles Kunkle

  • Adrian M. Ostfeld

  • Harold G. Wolff

Dr. Adrian Ostfeld wrote that, “There was surprisingly little disagreement about the classification of headache. Consensus was achieved by the fourth meeting.” He recalled that, “Our chairman, Arnold Friedman, MD, always provided each committee member with exactly 25 sheets of lined paper and 4 pencils sharpened to exactly the same length.” Ostfeld A. The Ad Hoc committee on Headache Classification. Cephalalgia. 1993; 13(Suppl. 12):11-12.