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Fall 2007

Leading Expert Establishes UCSF Headache Clinic

One of the world's leading headache experts has come to UCSF Medical Center in hopes of improving understanding of this debilitating disorder. Peter Goadsby, M.D., Ph.D., DSc, and seven of his colleagues from the University College London and the National Hospital for Neurology and Neurosurgery are setting up shop in San Francisco to look at basic mechanisms of headache and how therapies might treat it.

"We are trying to bring careful scientific method to the study of headache," says Abraham J. Nagy, M.D., the new clinical director of the UCSF Headache Center.

Headache is a little-appreciated illness. Often relegated to the category of side effect or symptom, headache can in fact be hugely debilitating and costly. Studies have shown that a day with a migraine can be like a full day of quadriparesis. In addition to personal costs, the economic costs of headache are significant, Nagy says.

In the past, headache treatments have come from happenstance discoveries. An example is verapamil, which started as a drug to treat heart rate disorders, Nagy says. "For decades, verapamil has been used to treat migraines, but we don't really understand precisely why it works," he says. "We don't understand the exact mechanism of action."

That lack of understanding reflects a historical dearth of knowledge about why the head actually hurts, but that has been changing in the last two decades. "Our understanding of headache and migraine pain is a hundredfold more than it was 10 years ago," Nagy says. "But we still have a long way to go."

The immediate cause of migraine pain is dilation of blood vessels, but the underlying cause of migraine is neurological. Altered nerve activity causes the release of inflammatory peptides in the area that surrounds these blood vessels, prompting them to dilate and swell. This accounts for the pounding or throbbing sensation many migraineurs experience.

In people with migraine, the threshold is lower for activating a pain loop that connects the nerves in these blood vessels with the brain stem through the trigeminal nerve. Various stimuli to the brain stem can prompt the cascade of symptoms that cause the release of these inflammatory peptides, initiating blood vessel dilation and pain. Pain and inflammation around the blood vessels in the dura send signals back to the brain stem that make the pain system more reactive to further slights.

Headache is just one symptom of migraine. Hypersensitivity of the nervous system can also cause a debilitating sensitivity to lights, sounds and smells as well as intractable nausea and vomiting.

Understanding what is going on during migraines and headaches in general has been furthered by technologies like functional MRI and other imaging procedures. "Under the right circumstances, we can actually see how the larger structures in the brain are involved during migraine and headache," Nagy says.

In the last five years, Nagy says, the biggest news in migraine research is the identification of several mechanisms that underlie regulating migraines. "We have a better understanding of the complex interplay of certain ion channel disruptions that are integral to triggering head pain," he says.

Goadsby, Nagy and their colleagues say that they came to UCSF because it offers an unparalleled opportunity to use basic and clinical research to systematically study and treat headache. Nagy cites many examples of opportunities at UCSF, such as the ability to work with neurologist Louis Ptacek, M.D., on the genetics of headache and with neurological surgeons like Philip Starr, M.D., Ph.D., who have been working on deep brain stimulation as a way to treat the neurological foundations of headache.

"We were drawn here because the neurological community at UCSF is phenomenal," Nagy says. "The neurology center is considered one of the top centers in the country."

For more information, call Abraham Nagy, M.D., at (415) 353-2273.

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