Migraine and cardiovascular disease: what cardiologists should know.

Migraine is a chronic neurovascular disease with a complex, not fully understood pathophysiology with multiple causes. People with migraine suffer from recurrent moderate to severe headache attacks varying from 4 to 72 h. The prevalence of migraine is two to three times higher in women compared with men. Importantly, it is the most disabling disease in women <50 years of age due to a high number of years lived with disability, resulting in a very high global socioeconomic burden. Robust evidence exists on the association between migraine with aura and increased incidence of cardiovascular disease (CVD), in particular ischaemic stroke. People with migraine with aura have an increased risk of atrial fibrillation, myocardial infarction, and cardiovascular death compared with those without migraine. Ongoing studies investigate the relation between migraine and angina with non-obstructive coronary arteries and migraine patients with patent foramen ovale. Medication for the treatment of migraine can be preventative medication, such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiepileptics, antidepressants, some of the long-acting calcitonin gene-related peptide receptor antagonists, or monoclonal antibodies against calcitonin gene-related peptide or its receptor, or acute medication, such as triptans and calcitonin gene-related peptide receptor antagonists. However, these medications might raise concerns when migraine patients also have CVD due to possible (coronary) side effects. Specifically, knowledge gaps remain for the contraindication to newer treatments for migraine. All cardiologists will encounter patients with CVD and migraine. This state-of-the-art review will outline the basic pathophysiology of migraine and the associations between migraine and CVD, discuss current therapies, and propose future directions for research.

Migraine and perimenopause.

Perimenopause and migraine are closely linked. The hormonal instability during the perimenopausal period not only causes vasomotor symptoms and mood disturbances, but also increases migraine incidence. Women do report new onset migraine during this period, but the increased incidence is reported by women with menstrually related migraine (MRM). The hormonal fluctuations can be stabilized with hormone replacement therapy (HRT), while simultaneously improving the migraine in some patients. The increased stroke risk in women with migraine with aura (MA) should be taken into consideration when intending to treat perimenopausal women with migraine with HRT.

Guidelines for the organization of headache education in Europe: the headache school.

According to its mission statement, one of the goals of the European Headache Federation (EHF) is to "educate Europe" about headache through the teaching of the key health personnel, such as young physicians and all those involved in headache management, about the seriousness of headache disorders. The countries of Europe share a close geographical proximity that facilitates international exchanges, particularly between university faculties. In recent years, this has, indeed, been the working basis of European educational endeavours in the field of headache. For a number of years, annual summer schools were organized in different European countries and a permanent Summer Headache School was set up in Cambridge (to be held every alternate year). The last summer headache school was held in Vilnius in 2002. In the past decade, a patronage scheme was also set up, which, combining two or more countries (one developed, one or more developing), allowed international exchanges of doctors and students for training purposes. In some centres, participants were also able to gain clinical practice and research experience by staying at the host institutions for extended periods of time. As a result of all this activity there have emerged, in Europe, "clusters" of people with a particular interest in headache. However, the rapid growth of insight into headache (new molecules, new headache categories, etc.) has contributed to a widening of the scientific gap between developing and developed countries. Moreover, in the past four years, due to the relative restriction of national/international drug company budgets, it has proved possible to organize only relatively inexpensive teaching courses. As a result, countries whose medical communities had been developing a "headache culture" now find themselves destined to be increasingly held back. Therefore, the EHF, in order to promote education on headache in Europe at national level, felt there was a need for guidelines for the organization of educational courses that meet uniform standards of excellence and in terms of code of conduct: guaranteed courses that will attract investors and those seeking to increase their knowledge, skills and understanding in the area of primary and secondary headache. The guidelines, presented here, specify the ideal length of a headache course, the number of lectures it should include, as well as the ideal number of participants and teachers. A sample course outline is provided, together with a checklist to help the organizers to meet the criteria for an EHF-approved headache school.