James C. Eisenach, M.D., Editor

Management of Migraine, by Egilius L. H. Spierings. Boston, Butterworth-Heinemann, 1996. Pages: 150. Price: $45.00.

If you are an anesthesiologist practicing pain medicine who needs to know more about headaches, then this new book offers a relatively painless way to expand your knowledge. Egilius Spierings, M.D., Ph.D., has written a scholarly and practical guide to the treatment of migraine.

Dr. Spierings starts with a broad and pragmatic discussion of the different views of the classification and etiology of migraine, and clearly demarcates when he is providing his own opinion. Next, he covers the diagnosis of migraine. Here, the pain-practicing anesthesiologist will find some useful pearls. For example, when considering whether transient, recurrent, sensory, or somatosensory symptoms are migraine aura, focal epilepsy, or transient ischemic attacks, he notes: with migraine aura, the symptoms develop over minutes; with epilepsy, the symptoms progress over seconds; and with transient ischemic attacks, the symptoms occur suddenly, without progression. In another example, the symptom complex of headaches always on the same side of the head and neurologic symptoms always on the opposite side is a warning of a possible underlying, structural, intracranial lesion. The persistence of neurologic symptoms between headaches is another such warning sign. An addition that would be nice in this section would be a discussion of guidelines regarding the ordering of brain imaging studies-Do all recent onset, recurrent headaches require computed tomography or magnetic resonance imaging?

The following sections include extensive reviews of the pharmacologic treatment of migraine-both abortive and preventive. In these two chapters, the author provides analysis and assessment of the studies that examine the efficacy of the various drugs. Most pain-practicing anesthesiologists will find these sections too detailed. I would have preferred more discussion on the mechanisms of action. Why is it that tricyclic antidepressants, serotonin antagonists, and calcium-entry blockers not only diminish the intensity of migraine attacks, but also diminish migraine attack frequency? Particularly useful elements of these chapters are his tables summarizing the efficacy studies. The table on abortive medications suggest that simple NSAIDs, with an efficacy of 60%, may be best as a first treatment, and that the highest efficacy is obtained with subcutaneous sumatriptan at 80%. The table of preventative medications indicates the highest efficacy for nadolol at 70%.

In chapter six, Dr. Spierings provides a very useful review of trigger factors, which includes menstrual cycling and hormones, stress, weather, and dietary products. Many of the cited studies make use of headache diaries. It would have been helpful if the author provided more guidance and instruction on the clinical use of such diaries (perhaps even in the earlier diagnosis chapter).

Dr. Spierings concludes with sections on pediatric migraine, cluster headache, and paroxysmal hemicrania. These are rarely seen in most Pain Management Clinics, yet these conditions are within the scope of algology. The practitioner should be familiar with the information in these brief chapters.

I was disappointed by the absence of any discussion of biobehavioral techniques, such as relaxation training and biofeedback, for the treatment of migraine. There is an extensive literature regarding the potential of these techniques as adjuncts and possibly primary treatments of migraine and other headaches. I would have enjoyed a critical review of these studies by Dr. Spierings. Similarly, Dr. Spierings mentions the roles of exercise and sleep disturbance as potential migraine triggers, but does not extensively review or discuss the importance of sleep regulation and exercise in the treatment and prevention of migraine attacks.

The summarizing tables and the complete index make this book a valuable reference text. It is best for those that have at least a little background or experience with general headache assessment and treatment. I would not recommend it to the expert headache practitioner (unless they are looking for a nice review of medication efficacy studies). The price is a little steep at $45, but perhaps the publishers will release a less costly, softcover edition. Overall, this is a worthwhile and easily readable book for the pain-practicing anesthesiologist.

Steven H. Richeimer, M.D., Director, Pain Management Center, Assistant Professor of Anesthesiology and Psychiatry, University of California-Davis, School of Medicine, 4150 "V" Street, Suite 1200, Sacramento, California 95817.