The Epidemiology of Primary Headache Disorders.

Defining the epidemiology of headache disorders is challenging given the prevalence of stigma and other harmful misconceptions about these diseases. Understanding the widespread impact of these disorders is essential when considering social and policy interventions to mitigate that impact. Tension-type headache is still widely considered the most common primary headache disorder, but population-based estimates of its prevalence vary widely. Migraine remains the most common headache disorder in patients who present for clinical care. Prevalence estimates have remained fairly stable over the last two decades (1-year period prevalence, United States: 18% of women and 6% of men). Recent studies indicate that people who identify as American Indian/Alaskan Native (AI/AN) have the highest migraine prevalence of any ethnic group surveyed, particularly among AI/AN men (15% vs. <10%). Studies in the United States also show an inverse relationship between income level and migraine incidence and prevalence, particularly for chronic migraine; factors mediating this relationship are difficult to define. There are many diseases comorbid with migraine, more so with migraine with aura. The burden of migraine is enormous: the Global Burden of Disease study indicates migraine is the number 1 cause of disability in women younger than 50 years and the number 2 or 3 cause of disability worldwide. Further study is needed into underdiagnosis, undertreatment, and persistent stigma associated with headache disorders, especially in underserved communities. Stakeholders including patients, providers, and governing bodies are affected by the results of epidemiologic studies and should all have a role in crafting and evaluating thoughtful and relevant questions and hypotheses in this field.

Headache Emergencies.

Headache is a common reason for seeking medical attention. Most cases are benign primary headache disorders; however, there is significant overlap between symptoms of these disorders and secondary headaches. Differentiating these clinical scenarios requires a careful history with attention to red flag symptoms and a neurologic examination. These details can identify dangerous disorders: subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, elevated intracranial pressure, hydrocephalus, cerebral venous sinus thrombosis, arterial dissection, central nervous system infection, and inflammatory vasculitis. Older, pregnant, or immunocompromised patients have a higher risk for secondary disorders; clinicians should have a different threshold to conduct evaluations in such patients.

Topectomy versus leukotomy: J. Lawrence Pool's contribution to psychosurgery.

Surgery of the mind has a rather checkered past. Though its history begins with the prehistoric trephination of skulls to allow "evil spirits" to escape, the early- to mid-20th century saw a surge in the popularity of psychosurgery. The 2 prevailing operations were topectomy and leukotomy for the treatment of certain mental illnesses. Although they were modified and refined by several of their main practitioners, the effectiveness of and the ethics involved with these operations remained controversial. In 1947, Dr. J. Lawrence Pool and the Columbia-Greystone Associates sought to rigorously investigate the outcomes of specific psychosurgical procedures. Pool along with R. G. Heath and John Weber believed that nonexcessive bifrontal cortical ablation could successfully treat certain mental illnesses without the undesired consequences of irreversible personality changes. They conducted this investigation at the psychiatric hospital at Greystone Park near Morristown, New Jersey. Despite several encouraging findings of the Columbia-Greystone project, psychosurgery practices began to decline significantly in the 1950s. The uncertainty of results and ethical debates related to side effects made these procedures unpopular. Further, groups such as the National Association for the Advancement of Colored People and the American Civil Liberties Union condemned the use of psychosurgery, believing it to be an inhumane form of treatment. Today, there are strict guidelines that must be adhered to when evaluating a patient for psychosurgery procedures. It is imperative for the neurosurgery community to remember the history of psychosurgery to provide the best possible current treatment and to search for better future treatments for a particularly vulnerable patient population.