Current Series: Chronic Migraine: Current Treatment Options and Recent Advances

Peter Goadsby, MBBS: Functional imaging in migraine has probably done more to aid in the rehabilitation of the condition into mainstream neurology than almost anything else that’s happened in the immediate history of the condition, because it points neurologists, physicians, and patients to the brain as the responsible organ, and that’s what neurologists do.

It provides a way of thinking—broadly speaking—about the pathophysiology of the condition. It gives it a certain element, you might say, that’s concrete. Functional imaging has shown the same basic structures change during an acute attack of headache, be they a patient with episodic or chronic migraines; so that’s been important. It shows the subtle structural changes, not lesions but markers of the pathophysiology. Most recently, what functional imaging has done is [it has] given us a way to start to think about the biology of the premonitory phase, or prodrome of migraine, which leads us to look at areas in hypothalamic region—for example, in midbrain and in the pons—all of which start to give you a way of thinking about the earlier stages of the attack.

One other important thing that functional imaging has done in the context of migraine is really expunge guilt from the blood vessels. It’s quite clear that the idea that migraine is due to vasodilation, and its treatment is about vasoconstriction, is just wrong. When one carefully looks at what blood vessels are doing in migraine, there’s no relationship to any change with pain. They don’t necessarily dilate, and they certainly don’t necessarily constrict with treatment. So functional imaging has not only put migraine firmly in the brain, but you might say it’s taken blood vessels off the hook.

(Transcript edited for clarity)