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Afridi et al1 concluded that activation of the dorsal pons in migraine supports a subcortical site of origin of the disorder. It is simplistic to assume that demonstration of cortical or brainstem activation in patients with migraine through positron emission tomography indicates the primary pathogenetic source.2 More than 5 decades ago, Leão’s3 experiments showed that retinal stimulation can also elicit spreading cortical silence and depression. Second, neuroimaging, however sophisticated, does not record early physiological events in migraine that occur in the prodromal or “preprodromal” periods; although the preprodromal phase is completely subclinical, the prodromal phase is characterized by subtle and protean clinical phenomena.4 Fundamentally, alterations of cerebral circulation or brain activation after onset of migraine aura or headache cannot be construed to reflect primary pathogenetic alterations. Third, inclusion of migraine patients with attacks as frequent as 4 per month1 assumes that cessation of pain indicates return to the basal physiological state by 72 hours; this assumption is erroneous.4 Fourth, Afridi et al1 offer no logical explanation why nonlateralizing ictal brainstem activation should manifest on the right side with brainstem deactivation on the left side regardless of the side of the headache. Fifth, the pathophysiological emphasis on the locus coeruleus1 is debatable; the locus caeruleus (and the dorsal raphe nucleus) does not directly innervate meningeal tissues and its involvement in migraine remains uncertain.5
To unravel the biology of migraine, the limitations of laboratory medicine, including neuroimaging, must be squarely acknowledged. Neuropharmacologically, a large body of available evidence does not support brain or brainstem neuronal origin for migraine.2 ,4 The study of Afridi et al1 clearly demonstrates secondary brainstem stimulation in migraine. There is, however, a wide conceptual gap between ictal brainstem activation/deactivation and primary pathogenetic aberrations in migraine. The obvious disconnect between basic sciences and primary headache research cannot go unaddressed.
Correspondence: Dr Gupta, Dubai Police Medical Services, PO Box 12005, Dubai, United Arab Emirates (dr_vkgupta@yahoo.com).
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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The Rational Clinical Examination Make the Diagnosis: Does This Patient With Headaches Have a Migraine or Need Neuroimaging?
The Rational Clinical Examination Original Article: Does This Patient With Headache Have a Migraine or Need Neuroimaging?
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