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  1. Gordian knot of migraine: serendipity, empiricism, hope, hype, hokum, and randomized controlled clinical trials

    Vinod Gupta, Dubai Police Medical Services, P.O. Box 12005, Dubai, United Arab Emirates

    6 June 2006

    Leiper, Elliott, and Hannaford present a qualitative picture of headache patients’ perspective [1]. The intensity of the quest of many individuals for an increased understanding of their condition and the development of their own explanations for their headaches is in direct proportion to the limitation of definitive knowledge about the origin or genesis of primary or vascular headaches. Migraine (and related idiopathic vascular headaches) is one entity in which technological, taxonomic, methodological (including statistical), and tautological sophistication has failed to offer any insight into disease mechanisms; also, the reductionist nature of ‘hard’ laboratory or epidemiological or clinical trials data has eluded researchers [2][3][4][5][6][7].

    Whether migraine is a specific disorder or a non-specific response to a variety of responses is also undecided. Consequently, efforts to prevent migraine vary widely and might involve pharmacological agents [8] or scalp injection of botulinum toxin [9] or closure of patent foramen ovale or atrial septal defect [10] or greater occipital nerve injection [11]. The advent of beta-blockers for migraine prevention was also a serendipitous event. To believe that a distinct pathophysiologic mechanism will be ultimately discovered for each of the nosologic entities currently delineated by the new version of the classification of the International Headache Society [12] appears to be a form of irrational scepticism [13]. Further elucidation of the “what” of migraine carries the unfortunate but subtle paradox that additional data will make little headway in understanding migraine unless the extant data is arranged into a vast intelligible synthesis ( “why” and “how”) that places key elements of migraine in a logically-defensible perspective-enhancing and hopefully insight-and experiment-generating bio-compatible model. Such conceptual groundwork is an important part of the migraine research process that cannot be supplanted by epidemiological data, laboratory studies or randomized controlled clinical trials.

    Key issues that might signpost the evolution of an overarching theory for migraine and other primary headaches have been underscored [14][15][16][17]. The basic obstacle to this process is the willingness of migraine researchers and therapists to comprehend how far assumptions and extrapolations ostensibly supported by non-directed accumulation of data in clinical trials or observational studies have removed current perception of primary vascular headaches from the biological truth. That migraine is a primary disorder of the brain remains a purely speculative hypothesis. Lay comprehension of any disease naturally follows and extrapolates from contemporary mainstream scientific concepts.


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    Competing interests