We assessed the prevalence of menstrual migraine and its restrictions on daily activities in a representative Dutch population sample of 1181 Dutch women, aged 13-55 years. Further, we evaluated the potential role of oral contraceptives, and how menstrual migraine is treated. More than half suffered from menstrual complaints, a substantial proportion reported headache or migraine as a frequent problem. Use of oral contraceptives seemed to reduce the occurrence of menstrual complaints, but not the occurrence of headache and migraine. In our study, the prevalence of menstrual migraine (3%) is lower than in the literature, most probably because we did not use a selected group of patients but a population-based sample of ordinary women. It was confirmed that attacks of menstrual migraine are more severe, of longer duration, and more resistant to treatment than migraine attacks at other times of the month.

Lithium is widely used in the prophylaxis of episodic cluster headache without formal evidence of efficacy. Placebo-controlled clinical trials are not easy in conditions characterized by frequent severe pain. In this study, it was assumed that lithium would work quickly if at all, and placebo response would be zero. Strict diagnostic criteria excluded uncertain or atypical cases. Patients were male in so-far untreated episodes expected to last for at least 3 weeks more. In a double-blind, placebo-controlled comparison of matched parallel groups, treatment was either slow-release lithium carbonate, 800 mg/day, or placebo. After 7 days, compliance was estimated by tablet count, blood was taken for lithium assay, efficacy was assessed (attacks stopped or substantially improved) and adverse reactions were recorded. The study was stopped after planned sequential analysis of the 27th patient (13 on lithium, 14 on placebo). Estimated compliance was usually but not always good. Plasma lithium levels were mostly in the range 0.5-0.6 mmol/l on lithium, zero on placebo. Cessation of attacks within 1 week occurred in two patients in each group, substantial improvement in 6/14 (43%) on placebo, 8/13 (62%; NS) on lithium. Only minor adverse events were reported. Lithium treatment was therefore associated with a useful subjective improvement rate but the assumptions made at outset had proved wrong. The trial was stopped because superiority over placebo could not be demonstrated. There were lessons for future trials.

Caffeine consumption may cause headache, particularly migraine. Its withdrawal also produces headaches and may be related to weekend migraine attacks. Transcranial Doppler sonography (TCD) has shown changes in cerebral blood flow velocities (BFV) during and between attacks of migraine. In order to examine whether headache and changes in BFV could develop from controlled caffeine alterations, 20 healthy volunteers without a headache history, underwent clinical evaluation, TCD and serum caffeine measurements on four occasions, comparing conditions of regular caffeine intake, caffeine withdrawal and "re-caffeination". After 24 h of complete caffeine abstinence, 10 suffered from moderate to severe headaches with complete recovery within 1 h after caffeine intake. The BFVs in both middle cerebral, both posterior cerebral and basilar arteries were higher following the withdrawal period, reaching statistical significance in the left middle cerebral basilar and both posterior cerebral arteries. BFVs decreased significantly within half an hour after caffeine intake in all subjects, and were similar to baseline values after 2 h. Our results emphasize the relationship between caffeine withdrawal, the development of headache and alterations in cerebral blood flow velocities. Also, these findings indicate that accurate interpretation of TCD measurements should account for the influence of caffeine on BFVs.

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