No abstract

SYNOPSIS To analyse from which extracranial tissues the pain of common migraine arises, 50 patients with typical common migraine were studied during the attack. Systematic recording of pain in 18 regions of the head and neck was followed by systematic palpation of 26 cranial and neck muscles and tendon insertions. All 50 patients were tender, and tenderness corresponded to pain in all but 2 cases. The most frequent sites of tenderness were: sternocleidomastoid, anterior temporal, neck and shoulder muscles, the coronoid process and occipital insertions. Referred pain was found in 73% of patients. Major pathways were sternocleidomastoid to temporofrontal area or occiput, occiput to vertex or temporofrontal area, neck to vertex or brow. The most tender spots were infiltrated with lidocaine 1.5% or saline double blindly. Results were judged clinically and by visual analog scales. 2648 patients were symptom free after 70 minutes which is significantly better than with medical treatment (p<0.01). There was no difference between lidocaine and saline. The study demonstrates that pericranial muscles and tendon insertions are important for common migraine pain.

Dale showed in 1906 in a seminal work that ergot inhibits the pressor effect of adrenaline. Stoll at Sandoz isolated ergotamine from ergot in 1918. Based on the belief that migraine was due to increased sympathetic activity, ergotamine was first used in the acute treatment of migraine by Maier in Switzerland in 1925. In 1938 Graham and Wolff demonstrated the parallel decrease of temporal pulsations and headache after ergotamine i.v. This inspired the vascular theory of Wolff: an initial cerebral vasoconstriction followed by an extracranial vasodilation. Dihydroergotamine (DHE) was introduced as an adrenolytic agent in 1943. It is still in use parenterally and by the nasal route. Before the triptan era ergotamine and DHE had widespread use as the only specific antimigraine drugs. From 1950 the world literature on ergotamine was dominated by two adverse events: ergotamine overuse headache and the relatively rare overt ergotism. Recently, oral ergotamine, which has an oral bioavailability of < 1%, has been inferior to oral triptans in randomized clinical trials. A European Consensus in 2000 concluded that ergotamine is not a drug of first choice. In an American review of 2003 it was suggested that ergotamine may be considered in the treatment of selected patients with moderate to severe migraine.