Category Archives: Archives

They Used to do What? Treatment Through the Ages: The middle years

The Middle Ages (800-1500) The next eight centuries saw few advances in headache treatment. Bizarre remedies were still widely used:

mid“The bones from the head of the vulture, wrapped in deerskin, will cure any headache; its brain, mixed with the very best of oil and put up the nose, will expel all ailments of the head.” – Incipit Epistula Vulturus, 800 AD

Pain-relieving medicines were first introduced in the 13th century, though these remedies bear no resemblance to the painkillers of today.

Italian monks placed cloths soaked in vinegar and opium on a sufferer’s head. The vinegar may have helped absorb small quantities of opium through the skin.

In the Americas, the Incas recognized the analgesic and anaesthetic properties of cocaine. They treated headache by dripping juice from coca leaves into an incision in a sufferer’s scalp.


The Renaissance (1600–1799)
17th century master clinician, Thomas Willis, made a tremendous breakthrough in renaissunderstanding by proposing that migraine was caused by swollen blood vessels in the head. His “vascular theory” became widely accepted within the medical community, and formed the basis of much 20th century drug development.

This new theory finally eliminated the dangerous practice of trepanation. Blood letting, purging and applying head poultices were still common, but with a different objective—to relieve excess blood flow around the brain.

To learn more about medical history, visit the WWW Virtual Library for the History of Science, Technology & Medicine.

Norway: Patient Organisation Takes Off

Norway is a country with a long coastline and deep fjords. It has a population of only 4.4 million, with an average of 14 people per square kilometer.

In Norway there is one patient-organization for headache sufferers, called Norges Migreneforbund (NMF), which was founded on 8 March 1994. The organization is run entirely by volunteers, but last autumn we appointed a daily co-ordinator. To date, NMF has 1050 members. The organization is structured with three levels, in the same way as the public health system in Norway.

Cultural issues

The status/perception of headache in Norway has generally been low, but it is growing. Migraine, like other predominantly female disorders, has had a low status among health professionals, the public and the field of headache in general. Migraine and migraine sufferers are not taken seriously in the workplace and this has contributed to their low self-esteem. In recent years, the government has started to take female diseases more seriously.

However, according to a national survey conducted last year, 80% of those suffering from headache do not consult a physician. In the countryside, taciturn, stubborn Norwegians try to hide the fact that they have a headache and do not even tell their spouse about it. On the other hand, many patients turn to the NMF. They have actually given in!

NMF recognizes that it has two main roles: to educate and to inform. We have produced written materials, including a newsletter (three times per year), brochures, and a poster to achieve these aims. We have also established an annual “Headache Awareness Day.” NMF receives media coverage on “Headache Awareness Day” and at other times when it is necessary to raise the national awareness.

Norwegians read more newspapers than any other nation in the world and NMF recognize the role of both local and national newspapers in educating and informing the general public. Our newsletter is sent to all GPs, neurologists, health stations for children and libraries in the country, and to the media. In this way we try to reach the sufferers, the general public, the physicians, and other professionals. This summer we are planning to start a series of seminars for pharmacy employees.

Health system

Healthcare in Norway is mainly public with some private practice. The health system has three levels. The smallest administrative unit is the municipality, which is responsible for primary healthcare. Specialists and county hospitals represent the second level. The country is divided into five health regions, which form the third level, each with one regional (University) hospital. In addition, the State runs a few specialized hospitals.

Allopathic treatments are generally available. There is no specialist emergency unit for headache patients; however, they are usually cared for through the ordinary healthcare channels. Hospital treatment is paid for by the State, but patients pay a small part of the cost for other treatments.

Alternative/ complementary treatments of various kinds are spread more or less all over the country. There is no registration or regulation of these professionals and the patients have to pay a consultation fee. A Parliamentary Report scrutinizing alternative medicine is currently on a “hearing round”. Within the public health system guidelines on the treatment and management of headache for health professionals are already available, although some physicians use the IHS Criteria for diagnoses.

The Norwegian Parliament decided a few months ago to establish a Center for Headache Disorders. This innovation will naturally have a considerable impact on headache sufferers, particularly for patients with more difficult and complex headaches. After an 8-year battle, it has now been agreed that the Center will be located at the University Hospital in Trondheim and will open in the year 2000. In the later stages, NMF fought shoulder-to-shoulder with the neurologists at the Trondheim University Hospital and greatly contributed to this success. This shows just how important a patient-based organization can be. We have power.

There are three main barriers to optimum healthcare for headache and migraine patients: (1) a lack of knowledge of headache disorders among GPs; (2) difficulties regarding access to knowledgeable neurologists; and (3) the fact that the level of professional care, within the health system, varies considerably within the country in this particular field.

From an economic point-of-view the State prefers that patients are treated within their own Health Region, in order to minimize associated travel costs. The State does not encourage the referral of patients outside their own Health Region.

Awareness of headache

“Everybody knows what a headache is.” However, detailed knowledge of headache disorders is poor among sufferers, the public and even health professionals themselves. Despite this, the level of awareness has improved over the last 10-15 years. NMF works to raise awareness among sufferers, the public and health practitioners through written materials, the “Headache Awareness Day” and the media. In addition, the pharmaceutical industry invites physicians to headache seminars.

One problem that we have to address is how to make ourselves heard amongst the vast amount of news and information generated by the media. Occasionally, the media take the initiative and write about headache diseases, particularly when they can present a special patient story. A second problem is the lack of understanding of headache within society in general. This may be because headache disorders are more or less invisible to other people. A particular issue for our organization is the lack of human and financial resources.

Education and support

The task of educating individuals and providing them with relevant information is obviously carried out by their healthcare physicians. For health practitioners, there are university-level courses and postgraduate courses arranged by the university medical faculties and the Norwegian Medical Association.

It is the job of NMF to work with the media, providing press releases and interviews to educate the public. As a supportive measure, NMF has opened a “Toll Free Telephone-line”, where the sufferer can talk to someone who knows what she/he is talking about — often for the first time in their life.

What can be done in the workplace? A lot. NMF has produced a poster which is designed for sufferers to give to their boss, colleagues, spouse or friends to increase their knowledge and understanding of headache disorders. The main employers’ organization in Norway (the NHO) has recently commenced a project which will examine how to improve the working conditions of employees with chronic diseases; NMF is participating in this study. We value highly such initiatives.

The main issue regarding education is the failure of various groups to take headache disorders seriously. There are still a number of myths about headache in Norway; for example, “there is no point in consulting a physician” and “drugs are not effective and may even be dangerous.”

Some groups ask themselves “what have I done wrong to be punished like this?” while other groups say “children cannot get a headache disorder” or “you look so well.”

Research

Research in Norway is funded in various ways: by the government via university budgets; by funds; by the pharmaceutical industry; by private donations; and, to a very small extent, via National Research Foundations. Clinical and laboratory research has been carried out in addition to drug studies. One particular line of research has been “unilateral headache,” and in recent years this has led to the discovery of CPH, SUNCT syndrome, etc.

Additionally, Doppler studies and headache epidemiology have been active fields of research. The findings of one large-scale epidemiological study, “The Vågå Study,” should be published in the near future. This is an exciting study in which almost all the adults in the Norwegian municipality of Vågå (nearly 2000 people) have been interviewed and examined by Professor Ottar Sjaastad, with regard to their headache. We can hardly wait for the results!

In 1984, the School of Headache was established by the Department of Neurology at the University Hospital, Trondheim. They have already successfully trained many young foreign physicians at this school. However, the main barrier for research remains the lack of funding.

General comments

Headache disorders are costly both for society and for the individual sufferer. Much research is going on throughout the world; however, even more is needed. We all have the same goal, and we need to unite. NMF wants to contribute to the success of the World Headache Alliance, for the benefit of us all. During the last 5 years, the NMF has come to recognize that there is an urgent need for a patient-based organization in Norway.

There is still a lot of work to do, but we have an optimistic attitude regarding the future, both on a national and international level. In Norway, we have a law stating that the government has to collaborate with the users of its services and that certain governmental documents have to be distributed on a “hearing round”. This also includes patient-organizations.

Migraine in New Zealand

A report by research company Colmar Brunton, puts the economic cost of migraine to New Zealand’s economy at $80 million. Based on an estimated 700,000 lost working days, this figure doesn’t allow for the additional costs to our health system when migraine sufferers seek medical help.

However, because migraine is not seen as “life-threatening”, its treatment receives a low priority in the government health budget. The emphasis in government policy is to limit the cost of health (currently about 20% of total government spending) by limiting access to prescription medicine through the imposition of restrictions and offering low subsidies to pharmaceutical companies. Imigran® (Imitrex®; sumatriptan) tablets, have only been funded by the government for less than 12 months and are currently the only fully funded prescription medicine of its type available.

Migraine sufferers, in the main, have to rely on their GPs for treatment. Currently, only about 30% of sufferers actually consult their doctor. In the past there has been little that doctors could offer in the way of effective medication. But with the advent of modern medicines such as Imigran® approximately 80% of migraine attacks can be successfully treated.

The New Zealand Migraine Sufferers Support Group

The MSSG has been operating for 5 years and offers assistance to sufferers and their families. National Director, Annette Hallam says the group has 1300 members and 22 support groups nationally. “Often the most helpful thing we can do is listen”, says Ms Hallam. “Talking on the phone, or even in person to someone who is a sufferer themselves can help relieve some of the pain and guilt people feel.”

Annette is the only paid employee of the NZMSSG and relies on the help of volunteers to spread the word. The NZMSSG regularly organise meetings with guest speakers that give sufferers the opportunity to both learn more about migraine, and talk to fellow sufferers. They also have brochures available and publish a quarterly newsletter.

Migraine Awareness Week

For the past two years the Group have run a Migraine Awareness Week, the aim of which is to encourage more people to seek treatment and to highlight the plight of migraineurs to the government in an effort to get them to fund new treatments.

A successful part of Migraine Awareness Week has been the use of public forums where migraine sufferers can get advice from local experts and share their experiences. In the attached photo, Dr Paul Fur (inset) who suffers from migraine himself told the meeting GPs need to be given more information on the subject. “Migraine is much more than a headache, often having dramatic effects on a person’s physical, mental, emotional and financial well-being. The migraine sufferer is often desperate in searching for a solution to their pain; the end result is that a number of medical specialties are consulted and many different treatments are tried.”

Dr Fur said that every migraine is different and there is no simple diagnostic solution. “Right from the start the patient should be involved in a dialogue with their doctor regarding treatment expectations, side effects, and ongoing communication regarding outcomes.”

Paul Fur believes that a migraine diary is a vital diagnostic tool. “In many cases you are not just dealing with migraine, but a complicated headache syndrome. It is therefore important to evaluate different treatment modalities to isolate the one or ones that offer the patient the best quality of life.”

At the same meeting, 13-year-old Rochelle Beyer addressed the meeting and told us her poignant story. Samantha Leggett also offered her perspective on migraine: Being a teenager is hard enough without having a condition that strikes without warning, makes you vomit and leaves you feeling weak for days on end. Samantha, now 14, had her first attack when she was 6 years old; she says the worst thing for her is having to take time off school. “If I miss a day from school, when I return my friends give me a hard time — they think migraine is just a headache. If only they knew.”

Treatment Survey

In a recent survey of members the NZMSSG asked a number of questions about the treatments people use or have tried. The following is a summary of responses:

Drug Usage & Effectiveness

Imigran® injection is the most widely used product (41%) and is used by twice as many people as the next most popular product (Migril 21%).

Relative effectiveness of each product can be measured in two ways. Firstly, by looking at individual effectiveness ratings which show a range from 4.6 (Imigran® injection) to 2.35 (Paracetamol) – based on a scale where 5 = very effective and 1= not effective at all.

Secondly, by comparing the percentage of people who have tried a particular product (at any time) and still continue to use it. The premise here is that the more efficacious a product is (for that individual) the more likely they are to continue to use it. Again, Imigran® injection is nearly twice as likely (65%) to be used on an ongoing basis as its nearest rival (Migril 36%).

In addition to the prompted products, respondents were asked to nominate others they had used. However, the majority were used by less than 5%, except for panadeine (7.6%) and Mersyndol (9.3%).

Alternative Therapies

The majority of those surveyed have tried alternatives such as prophylaxsis (62%) and various forms of natural therapy (65%); however, not many continue to use those therapies on an ongoing basis.

Preferred Method of Treatment

The majority preferred to take tablets (65%) compared with injection (27%).

Even though the Imigran® injection is the most widely used and the most efficacious, people would obviously prefer to have another method of delivery. 56% also said they would put off having an injection. Suppositories were surprisingly popular (47%), while Nasal Spray fared not much better than the injection (33%). However, it should be noted that there were not many respondents that had actually taken any form of nasal spray, so its low ranking is probably more a case of “fear of the unknown.”

Migraine Symptoms & Frequency

The vast majority of those responding experienced quite severe symptoms during a typical attack including nausea and vomiting (80%). 45% said they were completely unable to function.

40% said they had a migraine at least once per month, and 22% said they had more than one per week.

ACODOC: Colombian Association for the Study and Treatment of the Headache

The Colombian Association for the Study and Treatment of the Headache (ACODOC) was established on the 3rd February 1996. The organization is currently governed by very defined statutes and its aims are to promote the teaching of headache, to establish other patient support groups, make ethical rules which govern the treatment of migraine and to support the setting up of Headache Clinics in the country.

At the moment, we have 119 members in our organization including neurologists, general practice doctors, nurses and odontologists.

There are currently no specialized Headache Clinics in Colombia. In May 1999, the Colombian support group was set up for patients with headache. In the city of Medellin we also have the Antioquia Group for the Study of the Headache and they have their own page on the web http://www.geocities.com/athens/pantheon/8400/.

In October 1999 patients will be able to contact the support group by a free-phone number (sponsored by AstraZeneca) from anywhere in the country. The introduction of this service will enable us to extend our headache educational program.

Cultural issues

Colombia is a country of 35 million people distributed across an area of 33.6 million km2 with a population density of 1.2 people per km2. We enjoy a wonderful variety of climate due to the diverse topography of the country, with two seas, the wide mountainous area of the Andes, a rich and extensive plain and the exotic wild region of the Amazons. This also explains the great cultural and racial variety which exists. The official language is Spanish and the Catholic religion is practised by most of our people. The political system is democratic and our capital is Santa Fe de Bogota.

In our country, as in all the developing countries, there are a number of illnesses recognized as high-priority illnesses within the healthcare system. Regrettably, headache is ignored in real terms, along with its economic and social impact. However, the current ministers of health are beginning to recognize these problems. The system of social security which covers the whole country (Colombian Institute of the Social Security) now recognizes that migraine belongs in the group of illnesses which have a high economic cost. It has established treatment guidelines based on clinical evidence collected in 1997. Migraine, however, still lacks diagnostic recognition and appropriate treatment. The number of hours of teaching on headache in our medical schools are insufficient. Recently, the study of migraine has been included in the Neurology graduate programs across the country.

Within the social security system there is no register of headache patients. Migraine, epilepsy, dementia, cerebrovascular disease and extrapyramidal diseases are by far the most frequent consultations for the neurologist in their daily clinic and chronic daily headache is also very frequent. As in other countries, patients with migraine do not consult their doctor as often as would be expected from the prevalence studies. The general opinion is that suffering from headache is normal and that it is related to your life style, and this thinking is supported by the availability of over the counter (OTC) medications. The setting up of support groups and associations for the study of migraine has already high lighted the need to thoroughly investigate the magnitude and extent of headache in the population.

Health system

Since 1995, we have had the well-known social security system, known as law 100. The basic aim of the system is to increase the health awareness of the Colombian people. The law outlines that provision of healthcare should be shared with private and public companies, that its economic handling should be managed by the state with basis resources being distributed according to the number of patients in each company. Patients a on low income receive government subsidy and employers must provide healthcare to its workers without payment. Firstly, the patient has to be evaluated by a general practitioner (first level of care) before receiving neurological evaluation (top level of care). In many cases this delays the neurological evaluation of the patients and favors the overuse of OTC medications.

In future our association will ensure that the government and its agencies are fully aware of the magnitude of the economic impact of headache so that the right amount of attention can be focused on patients with headache. These initiatives are in the process of being set up.

The healthcare system lists specific medications that can be prescribed for a particular illness. However, the provision for migraine is poor, and the list does not include any of the new migraine medications (triptans). At the moment the new drugs have to be financed by the patient. Private practice exists but it is only available to a small group of people. Alternative Medicine is not subsidized by the state.

The institute of Public Health has introduced some basic guidelines for the treatment and management of migraine with the resources available within the system. Additionally, our association (ACODOC) has set up educational program designed for general practitioners across the whole country. Our quarterly newspaper HEADACHE TODAY (sponsored by Knoll) also contains information on treatment guidelines based on global clinical evidence.

Awareness of headache

The problem of migraine is only poorly recognized in our country, but with continued education this situation is improving daily. We already have a number of people who have trained in Migraine Clinics in others countries and they are now helping to promote interest in migraine in Colombia. Our organization is aware that training doctors outside this country is very expensive and often prohibitive. Unfortunately, state resources to support these initiatives are scarce.

Education and support

Support organizations, even though they are very new, are spreading across the country. ACODOC contributes to these initiatives. Next year we will hold our third National Congress and there will be opportunities for patients with migraine to participate. With the help of the WHA we want to ensure that our support groups grow in an ethical way, and that they do not experience the difficulties and barriers which arise because of the size of our country.

ACODOC fully endorses the formation of a patients’ support group in the second city of Colombia, Medellin.

We will soon have a free-phone telephone number and we hope that this will help the growth of the support groups. We also hope to widen the distribution of information on headache with the help of a page on the internet.

ACODOC pioneered the formation of the Latin American Association of Headache (ALADEC) which is the support group for South American countries. ACODOC actively participates with ALADEC through the Internet and its newspaper CEFANET (sponsored by Pfizer).

The Columbian politicians are pleased that ACODOC has agreed to donate part of its revenue from the National Congress to sponsor Residents who wish to study headache/migraine aboard. All Residents, with an interest in migraine, are eligable to apply to the selection committee.

With the support of the pharmaceutical industry, ACODOC organizes courses directed at students, general practitioners, internists and pediatricians in different regions of the country.

In October, we are hosting the Pan-American Congress in the beautiful city of Cartagena, which lies on the Caribbean coast. The topic of migraine will have a high profile with speakers from all over the world.

Research

It is difficult to say what the true prevalence rate for migraine is in Colombia. In 1995, a study was set up, EPINEURO, with the purpose of establishing which were the most prevalent neurological illnesses in our people. Headache was the most prevalent disease with 71.2 per 1000 habitants, whereas epilepsy which came second was 10.8 per 1000 habitants. The ratio of migraine prevalence was 2:1 for women and men. These results are similar to those found in others countries (personal communication from one author of the trial).

In another study, carried out in the emergency room of the University Hospital in Bogotá, they found that out of 105, 000 patients treated in the department in one year, 2.1% ( or 2228 patients), had headache and of these 56% were diagnosed with primary headache (migraine 35% and tension type headache 17.7%).

Within the next few months the Latin-American Association of Headache will start a population study of headache; this study is sponsored by pharmaceutics industry (Pfizer).

Several case reports (n=5) of SUNCT syndromes have also been published in recent years.

Finland with a headache

finland1Finland. If you look at the world map you will find it right there between Sweden and Russia. That’s right, it’s the country that looks like a lady in a long dress and with an amputated arm. Finland is probably best known for its many lakes. Indeed there are many — 187,888 to be exact. No wonder this sixth largest country in Europe can only fit 17 people to a square kilometre.

Finland is said to be the most on-line nation in the world. This nation of 5.2 million people has approximately 3 million mobile phones and 1.5 million internet connections — more than any other country per capita. In one aspect though, Finland is just like any other country, roughly 10% of the population lives under the shadow of migraine, and most of them are women.

Culture of sticking it out

We Finns are a somewhat curious nation, with a heritage of Scandinavian stubbornness combined with a twist of Slavic melancholy. The result is a culture of suffering and enduring privately all the pains and ailments life throws our way. We tend to sell ourselves short by thinking that our headaches — as vicious as they are — are not something we should bother doctors with.

Finland is also a highly work-oriented society where calling in sick or leaving the office early because of a headache — no matter how excruciating and disabling the pain might be — is simply not done. Just take two aspirins and live with it.

So, as long as even severe and constant headache is not considered ample reason to seek professional medical help, migraine remains an under-diagnosed and under-treated illness. It is estimated that as many as six out of ten migraine sufferers in Finland have not consulted a physician but keep treating their attacks on their own with over-the-counter painkillers.

Health care system

Finland has a health care system with three layers. Public health care would be the first layer and private health care the third layer. Layer number two would be the occupational health service, which intertwines with both public and private health services.

The public health care system is mostly state-financed — patients do pay a small fee every time they use the services — and it is built like a pyramid. On the bottom are the local health stations where people will go to see their primary care physicians or for basic laboratory tests. At the next level are city hospitals and at the top are the large university hospitals. University hospitals also have special units for treating i.e. allergies and skin conditions as well as different types of severe pains, migraine included. Private health care is also a very comprehensive system that offers a full range of medical services, from primary care physicians to specialists to state-of-the-art hospitals and special clinics — if one can afford them.

Employers usually provide health services for their employees. Companies buy the services from both the public and the private sector. Large companies even have their own health stations with company doctors and nurses.

Treatments (both conventional and alternative) are widely available throughout the country. The network of pharmacies is dense and the number of special health food stores is abundant. Most Finns still rely on conventional drugs and treatments but trying out alternative and natural remedies is steadily gaining popularity, especially with women.

The cost of any drug or treatment not prescribed by a doctor is carried by the patient. Prescription drugs fall into three categories depending on how large a percentage of the cost is covered by national health insurance — 50, 75 or 100 percent. Most drugs fall into the basic 50 percent category, including triptans.

Suomen Migreeniyhdistys plays an important role

The national patient association for migraine sufferers, Suomen Migreeniyhdistys (SMY), has two main objectives. The first is to educate and support migraine patients and the other is to increase public awareness of migraine.
finland2SMY now has over 2000 members who really need all the information and support they can get. At SMY, we do our best to provide both. Our newsletter is biannual and always packed with fact and extensive articles on migraine treatment, latest research, alternative treatment, pharmaceuticals and nutrition just to mention a few topics. (The picture on the left is the cover of our latest issue, featuring the new SMY logo.) But the most important thing is the personal touch and showing migraine sufferers that there are people who listen and understand without being condescending.

In the field of migraine awareness great progress has been made in the last few years. In fact migraine has become quite a fashionable topic in the media. But, there is still too much ignorance out there and SMY will have to work hard to educate the general public. Using the media — TV appearances, radio interviews, press releases, the internet — is one the best weapons we have, especially in an information society such as Finland. The key is to give migraine a face and a voice. Migraine awareness weeks are also becoming a “tradition.”

Research

One particular field of migraine research especially attracts Finnish researchers — genetics. Since 1993, a group of neurologists and geneticists have been working to locate and map the genes that make a person susceptible to migraine. It has been estimated that up to 50 percent of this susceptibility can be hereditary.

Finland is an exceptionally well-suited country for genetic research. The Finnish population descends from a fairly small original population and the country was a very remote and secluded part of Europe for centuries. For these reasons our genotype is fairly homogeneous and the gene pool consists of fewer genes and genetic mechanisms. So, it is fair to say that finding the ‘migraine genes’ might be easier in Finland than anywhere else.

This study is actually carried out in two parts — one with twins who show symptoms of migraine and one with families that show migraine prevalence. Of course, the success of this study relies heavily on a number of voluntary human ‘guinea pigs’. Luckily Finnish migraine sufferers seem to be exceptionally willing to contribute.

Overview of Canada

Background

Canada is a federation of ten provinces and three territories, which officially supports bilingualism (English/French) and multiculturalism. The geography of Canada is vast and varied, covering over 9 million square kilometers. The diversity of a population of just over 30 million continues to grow. The scope, complexity and diversity of Canada are both a challenge and strength. The Canada Health Act has been in place for many years. The principles of the Canada Health Act apply to the provision of medically insured services in all Canadian jurisdictions. The principles include:

· Universality · Portability · Accessibility · Comprehensiveness · Public administration

Profile

Help for Headaches (London, Ontario) and la Fondation québecoise de la migraine et des céphalées (FQMC; Montreal, Quebec) work together to ensure that migraine sufferers, regardless of where they live in Canada, are able to access the information, support and assistance they need to live stable and productive lives. The Organization for Understanding Cluster Headache (O.U.C.H. Canada) works to help Canadian cluster headache sufferers find the help they need.

Help for Headaches

Help for Headaches, with its head office located in London, Ontario, responds to approximately 1,000 cries for help each year. Like many non-profit organizations, Help for Headaches struggles hard to find financial support to sustain its important mandate.

The first priority for Help for Headaches is providing support and information to sufferers. Questions such as “…where can I find a good headache doctor…?” or “…are there any new treatments for headache pain?” and comments such as “…I’ve tried that already” are acknowledged along with the severity of pain. Individual sufferers are encouraged to educate themselves so they can effectively communicate these elusive symptoms to their doctor or healthcare professional.

The newsletter, Making Headway, is a means of reaching out to raise the level of awareness of this debilitating disorder and ensure that sufferers get the help they need to live stable and productive lives. Active since 1994, Help for Headaches produces a quarterly newsletter; raises awareness of migraine and headache; and promotes and provides educational opportunities for sufferers and healthcare professionals alike. Help for Headaches also manage a lending library, develop brochures, conduct workplace presentations and develop customized packages of information for headache sufferers. The organization hosts both local and international conferences featuring world-renowned headache experts.

La Fondation Québecoise de la Migraine et des Céphalées (FQMC)

La Fondation québécoise de la migraine et des céphalées (FQMC) is a federal charity committed to helping people who suffer from migraine and other headaches, creating awareness of their cause to promoting their rights and encouraging medical research.

LaFQMC is dedicated to providing quality services and programs to migraineurs, their families, and their friends, bringing each a message of hope and solidarity. It also takes a lead role in addressing the ignorance and indifference toward migraine and other headaches.

LaFQMC develops and promotes public awareness opportunities and encourages greater education about this disorder so that migraine is demystified and its impact on the lives of thousands and thousands is lessened. L’ENTÊTE, a quarterly newsletter, provides pertinent information on migraine and headaches. La FQMC offers public education conferences and forums, and provides a link to the community. It has developed an outreach program to address the issues about migraine in the workplace. This program provides for heightened employer and employee awareness of migraine and its impact in the workplace. A resource library can be accessed through laFQMC offices. Patient groups and networks are being formed in the province to provide a forum for discussion. In addition, laFQMC publishes booklets, brochures and fact sheets on migraine and other headaches, operates a provincial 1-800 number, and has a medical information line along with a website.

O.U.C.H. Canada (Organization for Understanding Cluster Headache)

O.U.C.H. Canada was formed in November 2003 by a group of individuals concerned about the lack of support for cluster headache sufferers in Canada. O.U.C.H. Canada joins its fellow cluster headache support groups O.U.C.H. USA, O.U.C.H. United Kingdom, and O.U.C.H. Italia. Incorporated as a society, based in Western Canada, O.U.C.H. Canada is currently awaiting non-profit/charity designation. The goal of the organization is to support cluster headache sufferers and work with Canadian doctors to someday find a cure and to raise public awareness and respect.

The O.U.C.H. Canada website offers a large variety of cluster headache educational information, links to other cluster headache sites, and a support board and chat site. There is also a link to a suicide hotline (cluster headaches are often referred to as “suicide headaches”), and printouts for patients to take to their doctors, employers or supporters.

The Migraine Association of Canada

After having functioned as Canada’s only national charity solely committed to providing quality services and programs to Canadians afflicted with migraine since 1974, the association was forced to declare bankruptcy in July 2001. The organization had answered approximately 20,000 individual requests for information annually. Attempts are being made to re-establish the organization in order to help the millions of Canadians who would benefit from their involvement and support.

Issues and concerns

In this time of government funding cutbacks and tight resources it becomes imperative that those of us involved in providing programs and services to migraineurs work collaboratively, whether it is to create greater public awareness about migraine, to fund research to find a cure, or to provide support, treatment strategies and information. The task ahead of us is enormous. The challenge will be to educate and inform Canadians about the seriousness and scope of migraine, to create greater levels of understanding of migraine, and to work toward finding a cure for migraine that will ensure a brighter future for our children and grandchildren.

Over the past several years, awareness of migraine has increased, and for the first time ever, migraine has been recognized by the World Health Organization as one of the top 20 disabilities in the world. In a 1998/1999 National Population Health Survey, migraine rated fourth (4% of males and 12% of females), following arthritis/rheumatism, non-arthritic back problems, and high blood pressure. Women between the ages of 25-54 are particularly affected. According to the Study, an estimated 1 in 12 (8%) of Canadians aged 12 or older – nearly 2 million people, have been clinically diagnosed with migraine. Earlier Canadian studies reported figures over 3 million, and the inconsistency is thought to lie in the differences in the way migraine was defined. However, because many migraine sufferers never actually receive a clinical diagnosis, the Study likely underestimates the prevalence of this disorder. Updated results will be available in the Spring, 2004.

The cost of migraine in the workplace is, of course, staggering with a reported 7 million workdays lost annually to migraine. Migraine sufferers reported an average of 1.8 disability days in a two-week period compared to 0.8 for non-sufferers. Migraine sufferers also tend to have other health problems, putting greater strain on an already stressed health care system. Nearly 30% of females and 20% of males with migraine (significantly more than those without migraine) reported other chronic conditions such as allergies, arthritis and rheumatism, back problems, sinusitis, and ulcers. In addition, 13% of female and about 7% of male migraine sufferers had experienced depression, more than twice the proportions of those without migraine.

In Canada, although many headache sufferers seek medical attention at some time, many do not return for follow-up medical supervision. Only 32% return for ongoing care and only 36% are undergoing medical supervision at any given point in time. Many sufferers rely on information and education available through Help for Headaches and la Fondation québecoise de la migraine et des céphalées.

Canada’s policy of multiculturalism does present a potential barrier for migraine sufferers in that information may only be available in English and French when in fact, for many Canadians English or French is a second language. The multicultural population in Canada is only beginning to find its voice and demanding better access to information.

Additionally, the geographic scope of Canada makes it difficult to ensure equal access to health services. For example, rural communities are unlikely to have a pain clinic or hospital or access to specialized services such as a neurologist. Members of these communities have to travel some distance to hospital or to visit a specialist. It should also be noted that access to needed health services outside of the insured system, including prescription medications, is seriously restricted for many low-income Canadians. The actual cost of migraine medication can be prohibitive.

Number of requests responded to annually:

Help for Headaches:1500

la Fondation québecoise de la migraine et des céphalées: 5500

Canada’s policy of multiculturalism does present a potential barrier for migraine sufferers in that information may only be available in English and French when in fact, for many Canadians English or French is a second language. The multicultural population in Canada is only beginning to find its voice and demanding better access to information.

Additionally, the geographic scope of Canada makes it difficult to ensure equal access to health services. For example, rural communities are unlikely to have a pain clinic or hospital or access to specialized services such as a neurologist. Members of these communities have to travel some distance to hospital or to visit a specialist. It should also be noted that access to needed health services outside of the insured system, including prescription medications, is seriously restricted for many low-income Canadians. The actual cost of migraine medication can be prohibitive.

Migraine and the healthcare system

The vast majority of Canadians who suffer from migraine have at some point made a trip to their family doctor/general practitioner (GP) looking for information and advice. A diagnosis may be made at this time or the family doctor/GP will refer the migraine sufferer to a specialist — either a neurologist or a headache specialist. However, information on migraine is readily available on the internet, in the library or through community associations. In 1998, The Migraine Association of Canada undertook a survey to determine what migraine sufferers felt were the most important sources of migraine information. The results were as follows:

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In large urban areas it is common to find headache specialists, migraine clinics or pain centers. However, if you live in the northern reaches of Canada you would have to travel to an urban center to access these services.

Emergency treatment for migraine is readily available through clinics and hospitals. Fourteen per cent of migraine sufferers in Canada have had to use the emergency department. The management of migraine in the emergency department continues to present a challenge. The care delivered to migraine sufferers, from diagnosis to treatment, is not standardized. Nonetheless, narcotics continue to be the agent of first choice in emergency departments in Canada. Unfortunately, because of this, a recent survey evaluating the outcome of patients being treated for migraine in two emergency departments (ED) in Eastern Canada concluded, “large numbers of migraine sufferers seen in the ED are probably receiving inadequate care or insufficient management strategies or medication at release”. Education and communication are important tools in managing migraine.

The practice of alternative and complementary medicine, such as the use of herbs and treatments such as chiropractic, acupuncture and massage, are on the rise in Canada. In fact, Canadians spend about $3.8 billion Canadian dollars every year on these therapies. Migraine sufferers rely on biofeedback, relaxation therapy, cognitive-behavioural therapy, hypnosis, acupuncture and other physical measures for relief of migraine. While few alternative and complementary treatments are covered by provincial healthcare plans, many are included in a number of third-party private insurance plans.

During 1997, in an effort to improve the diagnosis and management of migraine, The Canadian Headache Society drafted Guidelines for the diagnosis and management of migraine in clinical practice. The guidelines were based on a consensus of Canadian experts, and were updated in 1998, and again in 2003, to include Guidelines for the nonpharmacologic management of migraine in clinical practice. Canadian physicians now have tools for accurate diagnosis and management of migraine for both conventional and alternative treatment strategies.

Barriers to health services in Canada include access, income level, education level, and cost of services not insured as part of the basic system such as medication. For many migraineurs the cost of medication is a factor.

Awareness

Awareness of migraine among the general public has grown in the last 25 years, yet despite best efforts migraine is often viewed as ‘just another headache’. Help for Headaches and la Fondation québecoise de la migraine et des céphalées work to raise awareness and focus attention on migraine as a serious neurological disorder every November.

The collective efforts of those involved with migraine will ensure greater effectiveness and improved visibility for migraine. Migraine Awareness Week/Month is a national campaign to spread knowledge and understanding of migraine in the general public, as well as to raise funds to support essential services and the development of a research program. Considerable energy, creative abilities and talents are focused on promoting understanding and education in this serious neurological disorder. This single goal is slowly being realized after years of effort.

Chapters, self-help groups, sponsors, supporters and volunteers from locations across Canada participate in Migraine Awareness activities by hosting press conferences, sponsoring educational forums, distributing information, selling jellybeans etc.

In addition to Migraine Awareness activities, Help for Headaches and la Fondation québecoise de la migraine et des céphalées participate in awareness activities such as press conferences, forums, etc. on an ongoing basis directed towards a variety of target audiences such as the medical/healthcare community, workplaces, self-help/patient support etc. Public awareness and education are key to the strategic direction.

Research

Migraine research has largely been a function of the pharmaceutical industry as it works to develop effective medication for managing migraine. Research funding in Canada comes from five principle sources: the federal government, the pharmaceutical industry, the charitable sector, private sector and universities. The level of government-sponsored funding for research has fallen dramatically over the last ten years and this has resulted in a ‘brain drain’ and few research projects being undertaken.

Migraine research in Canada is still in its early stages of development although Canadian researchers have been active in supporting clinical trials etc. There are a few programs that are interested in genetics and physiology. The research industry in Canada would grow and flourish if more funding was available to support research initiatives.

Conclusion

Migraine is consistently under-diagnosed and misunderstood. Migraine is a complex disorder and managing migraine is all about education: education by and for the migraine sufferer; education by and for the medical/healthcare community; education by and for families, colleagues, researchers; and education by and for the workplace. It is through education that we achieve enlightenment.

In Canada, the day of migraine enlightenment is still a long way off.

They Used to Do What? Treatment Through the Ages: Recent History and Beyond

The 19th Century (1800-1899)

vicPhysicians in the 19th Century treated headache far more conservatively than their predecessors. Most treatments were based on drugs with proven effectiveness.

As early as 1868, doctors used crude preparations of ergot alkaloids to reduce engorgement of blood vessels in the head. Results were inconsistent, probably due to unrefined methods of extracting active substances from the ergot fungus.

William Gowers stressed the importance of correcting underlying disease and avoiding triggers for migraines in 1888. Gowers also distinguished between treatments that could prevent migraines, and those able to abort attacks already underway.

Nineteenth century medical opinion on the cause of migraine divided into two camps—those agreeing with Willis’s vascular theory and those supporting Edward Living’s neurogenic theory. Living believed migraine to be caused by “nervous storms” in the brain. This debate continued well into the 20th century.

There was little professional interest in the 19th century in what we call “tension headaches.” Neurologists believed them to be of psychological origin, and prescribed a variety of treatments – complete bed rest, strenuous activity, and psychoactive drugs such as laudanum and marijuana.


The 20th Century (1900–1999)

New therapies to treat headache developed slowly during the first part of the 20th century. Ergotamine tartrate was isolated in the laboratory in 1920, and introduced into clinical practice for treating migraine in 20th1925. Ergotamine worked by constricting blood vessels in the head, confirming the “vascular theory” proposed by Willis three centuries earlier. In the 1980s, another ergot alkaloid, dihydroergotamine (DHE), was found to be an effective treatment for chronic daily headache.

Around mid-century, researchers began to suspect that disturbances in the brain’s serotonin level played a role in migraine. The drug, methysergide, a serotonin antagonist that prevents migraine attacks, was introduced into clinical practice in 1958.

In recent years, new technologies have made it possible for researchers to identify serotonin receptors throughout the body. It is now believed that serotonin levels actually decrease at the onset of a migraine attack, causing blood vessels to dilate and surrounding tissues to swell. This triggers pain.

Studies show that stimulating certain subtypes of serotonin receptors can constrict blood vessels in the head and stop an acute migraine attack. Because ergotamine and DHE also stimulate dopamine receptors, they can cause nausea and vomiting. This information has enabled researchers to develop the new triptan drugs that switch on appropriate serotonin receptors, and provide effective migraine relief without many of the side effects of earlier drugs.

Some drugs developed for other purposes are also proving effective against migraine. These drugs include propranolol, verapamil, amitriptyline, valproate and gabapentin.


The New Millennium

futureIn the last few years there has been considerable interest in the role nitric oxide plays in migraines. Agents that block production of this chemical are currently being investigated as new treatments. Researchers are also looking at a group of compounds called neurosteroids, at the possible role of the neurostransmitter dopamine, and at agents that stimulate serotonin receptors.

Although migraine has been recognized as an inherited condition for over 1,000 years, the specific genetic anomalies linked to migraine are only now starting to be identified. This information will enable researchers to develop migraine treatments that act at the level of our genetic make-up.

Research into treatment for many other types of headache has not progressed as quickly as that for migraine. Hopefully this focus will change, and the new millennium will bring renewed interest in the origins of and treatment for non-migraine headaches.

To learn more about medical history, visit the WWW Virtual Library for the History of Science, Technology & Medicine.

Celebrities Suffer Migraines Too

Some of the world’s most famous and influential people—statesmen, military leaders, writers, painters, psychologists, philosophers, actors, musicians and sports stars—have suffered from migraine.

The politicians
caeserRoman dictator Julius Caesar and French emperor Napoleon Bonaparte suffered from migraine, as did U.S. president and principal author of the Declaration of Independence Thomas Jefferson. Both Robert E. Lee, Commander-in-Chief of Confederate armies during the American Civil War, and Ulysses S. Grant, the Union general who overcame Lee’s troops and went on to become U.S. president also suffered from migraine.

The writers
catMigraine has influenced the work of many writers, among them Lewis Carroll, Virginia Woolf, and Miguel de Cervantes. Carroll’s Alice’s Adventures in Wonderland, and Through the Looking-Glass and What Alice Found There may have drawn from the feelings of bodily distortion and light sensitivity experienced by some people with migraine.

Virginia Woolf’s works include A Room of One’s Own, Mrs. Dalloway and To the Lighthouse. Cervantes is best known for his satirical masterpiece Don Quixote.

The painters
vangoghImpressionist painter Vincent Van Gogh is reputed to have suffered from severe migraines. Some speculate that his strokes of pure color were inspired by visual disturbances from migraine auras. Van Gogh’s works include some of the most acclaimed paintings ever created – Sunflowers, Irises and The Night Café.

The “Seurat effect,” a term used to describe the visual phenomenon of a scintillating aura, takes its name from another Impressionist artist, Georges Seurat. Seurat pioneered the pointillist technique of building up images from small dots of color.

The thinkers
freudSigmund Freud, the “Father of Psychoanalysis,” is thought to have suffered from migraine. Freud’s radical views challenged 20th century society’s view of itself and the world with his provocative theories on the psychology of human sexuality and dream interpretation.

The German philosopher and poet Friedrich Nietzsche was also plagued by migraines. Nietzsche, considered one of the most influential thinkers of the 19th century, produced many works during his short career. These include The Birth of Tragedy, Daybreak, The Gay Science, Beyond Good and Evil, On the Genealogy of Morals, The Antichrist and The Will to Power.

The entertainers
shoesMusical legend Elvis Presley, actress and comedienne Whoopi Goldberg, British royal family member Princess Margaret, Denver Broncos player Terrel Davis, and actress Susan Olsen (Cindy Brady of Brady Bunch fame) are just some of the 20th century’s famous migraine sufferers.

Needless to say, if you suffer from migraine, you’re in good company.

They Used to Do What? The History of Headache Treatment: The Early Years

Early BC

bcOur earliest ancestors believed evil spirits who lived inside or cast pain into the head caused headaches. Headache treatment involved appeasing these spirits with prayers and offerings, and by anointing the head with foul-smelling substances to drive the spirits away.

If that doesn’t sound bad enough, think about this: Severe headaches were treated by trepanation—drilling a hole in the head to release evil spirits!

Late BC/Early AD
More physical causes for headache began to be recognized around 600 BC as the belief in evil spirits fell way. Physicians’ potions and primitive surgical procedures – practices often less effective and more harmful than earlier “cures” – replaced the magic and prayers of the priesthood.
adThe Greek physician, Hippocrates (circa 400 BC), attributed headaches to noxious vapors rising from the liver to the head. He recommended applying leeches, bleeding, and, in extreme cases, trepanation.

The word, “migraine” originated during this period with the Roman physician, Galen (circa 160 AD). His term, “hemicrania” – for one-sided head pain – evolved over time to become the word, “migraine” we know today.

Headache Studies in Brazil Uncover Healthcare Challenges

Source: Etiology and Distribution of Headaches in Two Brazilian Primary Care Units Headache March 2000

Background: Studies have shown that headache is one of the most frequent symptoms reported in medical practice, resulting in significant medical services cost and loss of patient productivity, as well as reduced quality of life. However, few studies of headache have been conducted in developing countries.

The Health Care System in Brazil

For people in Brazil seeking medical care for headache, primary care units within the public health care service are their first resource. Many patients seeking such care have no health insurance and as members of the “underprivileged classes” do not have the financial means to seek private health care. These patients are seen by general clinicians.

The public health system in Brazil is said to function “in a precarious manner”. The primary care units generally do not have enough staff and deal with an enormous number of patients.

The Basic Public Health Care Units Studied

The two public health care units examined in this study were located in the interior of the State of Sao Paulo in Brazil. The first, located centrally in the town of Sao Carlos provides care for all 160 000 inhabitants of the town. The second, located on the northern edge of the town of Ribeirao Preto cares for about 120 000 people.

The units were studied over an 8-month period in 1998. Of the 6006 patients seen by one physician in this time period, 561 of these patients presented with a main complaint of headache.

The Purpose of the Study

The purpose of this study was to determine:

which patients seek primary health care services with headache the various types of headache in the population the impact of care for headache patients on the basic public health care system

The Results of the Study

561 of 6,006 patients seen had a main complaint of headache – that’s over 9 percent of patients. Of those, 312 or around 56 percent had a primary headache (a headache that wasn’t the result of another illness or medical condition). The remainder of the patients had headaches that resulted from a neurological disorder (such as head injury or brain tumor) or a disorder of some other bodily system (such as substance abuse). Migraine headache was the most common type of headache affecting 45 percent of all those with headache.

There were more females seen for headache than males. Women were much more likely to suffer from migraine type headache than men – whether they were suffering from an actual migraine or a headache secondary to some other illness or condition. More women also experienced tension-type headaches than men. However, when men had a headache as a result of another medical illness or condition they were more likely to experience it as a tension-type headache. Headache appeared to be more common in women and men in the age group from 20 to 40 years.

What Does it Mean?

The number and percentage of patients seeking treatment for headache from basic primary care public health care units in Brazil is considerably high. Therefore headache places a large demand on these units and contributes considerably to their expenses.

The results show that clinicians working in the primary care public health care units in Brazil need to be continually educated about headache – and the criteria used to diagnose headache recommended by the International Headache Society (I.H.S.) should be emphasized. This would help healthcare professionals to properly diagnose and treat headache, preventing repeat visits to the units by patients. This would also improve the efficiency of the public health care units and the patient’s quality of life.

Finally, based on the results of the study the authors conclude that headache needs to be considered a public health problem in Brazil – and around the world. Appropriate resources and efforts are needed to adequately deal with the public health issue of headache.