figure a

Since 1938, when Graham and Woolf did their seminal work on dilation of the extracranial arteries of the carotid system and the beneficial effect of ergotamine, migraine was considered a vascular disease. Over the years, various well known researchers have demonstrated that there is no direct relationship between the pain of migraine and the state of the blood vessels. In the last several years it has become clear that the cerebral cortex, as well as the nociceptors of the trigeminovascular system, and their connections into the trigeminal nucleus caudalis are integrally involved in the migraine process and maybe in the pain itself. Glutamate and other brain chemicals are probably vital in this process. Although there is still some intense interest in the extracranial carotid system in migraine pain production, the jury is still out as to what importance this vascular system plays in the pathophysiology of migraine. The overwhelming evidence seems to side with the neuronal theory of migraine, but blood vessels may still be part of the process.

Alan M. Rapoport, M.D.

Clinical Professor of Neurology

The David Geffen School of Medicine at UCLA

Los Angeles, CA, USA

Founder and Director-Emeritus

The New England Center for Headache

Stamford, CT, USA