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According to its mission statement, one of the goals of the European Headache Federation (EHF) is to "educate Europe" about headache through the teaching of the key health personnel, such as young physicians and all those involved in headache management, about the seriousness of headache disorders. The countries of Europe share a close geographical proximity that facilitates international exchanges, particularly between university faculties. In recent years, this has, indeed, been the working basis of European educational endeavours in the field of headache. For a number of years, annual summer schools were organized in different European countries and a permanent Summer Headache School was set up in Cambridge (to be held every alternate year). The last summer headache school was held in Vilnius in 2002. In the past decade, a patronage scheme was also set up, which, combining two or more countries (one developed, one or more developing), allowed international exchanges of doctors and students for training purposes. In some centres, participants were also able to gain clinical practice and research experience by staying at the host institutions for extended periods of time. As a result of all this activity there have emerged, in Europe, "clusters" of people with a particular interest in headache. However, the rapid growth of insight into headache (new molecules, new headache categories, etc.) has contributed to a widening of the scientific gap between developing and developed countries. Moreover, in the past four years, due to the relative restriction of national/international drug company budgets, it has proved possible to organize only relatively inexpensive teaching courses. As a result, countries whose medical communities had been developing a "headache culture" now find themselves destined to be increasingly held back. Therefore, the EHF, in order to promote education on headache in Europe at national level, felt there was a need for guidelines for the organization of educational courses that meet uniform standards of excellence and in terms of code of conduct: guaranteed courses that will attract investors and those seeking to increase their knowledge, skills and understanding in the area of primary and secondary headache. The guidelines, presented here, specify the ideal length of a headache course, the number of lectures it should include, as well as the ideal number of participants and teachers. A sample course outline is provided, together with a checklist to help the organizers to meet the criteria for an EHF-approved headache school.

Headache is an extremely common disorder which has a marked impact on the utilisation of healthcare resources and constitutes a considerable socio-economic burden. The related costs, both direct and indirect, are especially high in developed countries, since headache predominantly affects an economically-active section of the population. The Diagnosis-Related Groups (DRG) system, a method for reimbursing healthcare structures for patient admissions, was introduced in Italy in 1995. The aim of the system was to control public health expenditure and to promote better distribution of financial resources. Here, we report the results of the application of the DRG system to headache patients admitted to the Department of Neurology of the University of Pavia in 1996 and 1998. The financial analysis revealed high fixed costs (hospital running costs per days of hospitalisation); by contrast, the impact of the variable costs (those relating to the direct management of the individual patient, i.e. examinations, therapeutic interventions etc.) was low. It was found that reducing the number of days of hospitalisation increases the hospital's income and reduces the mean loss incurred in each DRG. It is therefore suggested that a complete approach to the management of headache must include educational programmes for patients and general practitioners, and that access to headache centres and to hospital care should be restricted to cases of acute, severe headache, or recurrent, chronic headache with/without drug abuse or dependence.

The purpose of this study was to assess the reliability of a 3D kinematic method of evaluating movements of the cervical spine. Range of motion (ROM) of the cervical spine was evaluated in 8 control subjects during flexion-extension, rotation and lateral bending movements. The test was repeated on two separate occasions. The ROM test-retest difference ranged from 1.42 degrees for right axial rotation to 9.11 degrees for left axial rotation. The test showed good reliability, with an intraclass correlation coefficient which was higher than 0.74 in extension movement and excellent in flexion, axial rotation and lateral bending. In conclusion, the method proposed for the 3D kinematic analysis of neck movement proved to be useful and non-invasive and to show good-excellent reproducibility. Furthermore the method is easily applicable in clinical practice to evaluate neck function in cervical spine disorders.

Greater occipital nerve (GON), supraorbital nerve (SON), and minor occipital nerve (MON) blockades-in this sequence-were carried out on the symptomatic side in patients with chronic paroxysmal hemicrania (CPH) (no = 6) and hemicrania continua (HC) (no = 7). Prior to the blockade, indomethacin was discontinued for a sufficiently long time (24 h) to allow a constant flow of attacks/constant pain. The local anaesthetic agent used was lidocaine. The blockades were invariably negative in CPH. In HC, the GON and MON blockades generally had no positive influence. The pattern as regards SON blockades was slightly different, in that the pre-test average VAS-value of 7.3 decreased to 4.6 (p < 0.05, Student's t-test, and p = 0.065 Wilcoxon) and-on an individual basis-decreased in 4 out of 7 patients. GON/MON blockades will help distinguish CPH/HC from cervicogenic headache. SON blockade will have to be carried out in a good-sized series of HC patients in order to establish more concrete evidence of the putative effect in HC. SON blockades may eventually also aid in the distinction between HC and supraorbital nerve neuralgia (where the blockade effect generally seems to be complete).

A 45-year-old female migraineur with a long-standing history of drug-induced headache is described. She had been abusing caffeine (250 mg/day) and aspirin (5 gr/day). On the third day after discontinuation a withdrawal syndrome characterized by headache and a generalized tonic-clonic seizure occurred. The temporal association makes it likely that the convulsion episode in an integral component of the withdrawal syndrome in this patient. This extra feature of the withdrawal syndrome has never been described after caffeine and/or aspirin interruption. Possible pathogenetic mechanisms are discussed.

Bilateral sympathetic skin response (SSR) was evaluated in 25 normal subjects aged (29 +/- 5 years). The stimulation (an electrical pulse train randomly applied to the sural nerve) was equal to 0.5-1.0-1.5 times the nociceptive flexion reflex (RIII) thresholds. This method allowed us to quantify the pain threshold, since a close relationship between the RIII threshold and subjective pain threshold has been described. Decrease in latency, increase in amplitude and duration were observed when increasing intensity of stimulation was used. The right-side stimulation produced significantly shorter latencies and higher amplitudes than the left one. The asymmetry index showed a trend of larger responses on the left hand and shorter latencies on the right hand in males. Females displayed less left-right asymmetry than males. A positive correlation was recognized between RIII threshold and amplitude and duration of SSR. Test-retest evaluation in 12 individuals revealed good reproducibility of SSR in terms of latency and duration, while amplitudes showed large variability. The accuracy of SSR response concerning latency and duration was better (range 0.88-0.92) when 1.5 RIII threshold was used, showing that painful stimulation should be used to obtain reliable SSR in clinical practice.

A comprehensive record chart for the study of chronic daily headache (CDH) is presented. The record chart contains 11 parts (232 items) concerning: sociodemographic data, physiological history, female reproductive life history, family history, pathological history, drug abuse, headache history, headache clinical features, prophylactic therapy, instrumental investigations, and physical and neurological examination. Furthermore, three attached special charts are illustrated which concern, respectively, the cervical spine examination, oromandibular function examination and the assessment of analgesic use.

The case of a 28-year old woman with headache resembling hemicrania continua (HC) is described. Since her childhood she had a history of right-sided, side-locked, painful headache attacks, with increasing attack frequency during the last two years, each attack lasting around 24 hours. There were only a few "migrainous" symptoms and signs, thus no photo- and phono-phobia and no vomiting. Only occasionally did she have slight nausea. The clinical picture as well as the complete indomethacin effect suggested a case of HC. However, the indomethacin effect faded away after > 2 months. At that time, a CT scan revealed a tumor in the right sphenoidal bone involving the clinoid process and the base of the skull. A biopsy of the tumor during craniectomy showed a mesenchymal tumor, and the patient was considered inoperable (April, 1989). After cytostatic treatment, she is back in full time work; the headache disappeared and it still has not recurred after approximately 2 years of observation. Neuroradiological investigation should, therefore, be included in the work-up of patients with HC. At the present stage of knowledge, neuroradiological investigations should probably also be included when faced with a typical clinical picture.

Pupillometric studies were carried out in 9 patients with chronic paroxysmal hemicrania (CPH), in 10 patients with hemicrania continua (HC) and in age- and sex-matched controls (n = 12-17). Studies were carried out in the basal condition and after instillation of 2% tyramine, 1% OH-amphetamine, or 1% phenylephrine. The pupillary response to tyramine in HC was more marked than in controls on a percentage increase basis, but not so much when the increment is calculated in absolute values. In this series, there was no asymmetrical response (relative miosis on the symptomatic side) like in previous case reports. The pupil reaction was less in HC than in CPH after hydroxyamphetamine instillation and without any marked asymmetry. There was no definite evidence of supersensitivity to a directly acting sympathicomimetic agent, phenylephrine. No gross abnormalities as regard the sympathetic function in HC was thus observed. The asymmetry on tyramine testing differed in CPH and HC (most marked in HC). No major emphasis should probably be attached to this finding, since on testing with OH-amphetamine, a similar substance, this finding was not reproduced.

Pain perception threshold (PPT) in the head was assessed with a pressure algometer in 40 control individuals (24 females and 16 males). Threshold was assessed at 11 symmetrical points on each side. The average threshold for each side was calculated, and differences between two sides were evaluated with an asymmetry index. Subjects were studied in relation to age and sex, and any difference in the symmetrical perception of pain on the head was registered. The deltoid muscle was chosen as a reference point, since it is rarely a site of trigger points. The reproducibility of the method was satisfactory. A significantly positive correlation was found between PPT value of the head and the deltoid muscle. There was no tendency to rise or fall in PPT during the same "session", which consisted of 3 separate complete measurements. The mean of mean values showed that there was little asymmetry as for the thresholds pertaining to the head in the total material. Age and sex apparently played little role as for the outcome of the test. The assessment of PPT in the head might be a useful tool in the study of lateralization of pain in unilateral headache syndromes.

A comparison of the heat- and pilocarpine-induced forehead sweating patterns was carried out in 8 patients with "Hemicrania continua" (HC) and in healthy subjects (n = 17 and 14 for the two tests, respectively). The results were compared with those obtained in 8 patients with chronic paroxysmal hemicrania (CPH). Unlike what has been demonstrated in cluster headache, CPH and HC patients showed no symptomatic/non-symptomatic side asymmetry or medial-lateral preponderance after sweat stimulation by heating or pilocarpine, exceeding those observed in the control group. The only exception seems to be a significant relative increase in medial forehead sweating on both sides in HC patients when compared to controls during the heating test. With these variables, no evidence for any difference of major importance seems to exist between the two headache forms.

Ipsilateral sympathetic deficits, that is symptoms and signs consistent with a diagnosis of Horner's syndrome, have been described in patients who have undergone thalamotomy for dyskinesia as well as for parkinsonism. The present patient material consists of 10 patients with parkinsonism who had undergone stereotactic surgery. Since anhidrosis and miosis are two integral components of Horner's syndrome, forehead sweating and pupillometric response to sympathicomimetic agents have been investigated in this preliminary work. The tests were carried out a considerable time postoperatively. Sweating was stimulated in two different ways: by body heating and by parenterally administered pilocarpine. OH-amphetamine and phenylephrine (an indirectly and a directly acting sympathicomimetic agent) were used in the pupillometric tests. The results were compared with those obtained in a healthy control group. With the OH-amphetamine test, there were some indications of a changed sympathetic activity on the surgical side. However, when comparing these results with those obtained by the phenylephrine test, the inference seems to be allowable that parkinsonian patients operated in this way (target area: ventro-oral thalamic nuclei (Voa and Vop) and the reticular thalamic nucleus) show no definite sympathetic supersensitivity at the late postoperative stage. Our data suggest that the response pattern of the pupils and the sweat glands may be related to the surgical method used and/or to the interval from operation to investigation.

Eye drops of naloxone were applied and pupillary diameters recorded at standard time intervals in 18 healthy controls and in 20 patients with episodic cluster headache during pain free intervals by means of a pupillometer. In the basal condition, the mean symptomatic side pupil in the cluster headache group was significantly smaller than the pupil of controls. Patients in the cluster period had a significantly smaller symptomatic-side pupil when compared to patients outside the bout. After naloxone, the pupils on the symptomatic as well as on the non-symptomatic side were significantly smaller than those in controls when expressed in mm. The difference between patients and controls persisted, and was, grossly speaking, of a not widely varying magnitude during the drug test. This study thus does not render any definite evidence for a role of opioids in the mechanism underlying the miosis of cluster headache.

Tyramine pupillometry was performed in 27 cluster headache patients and in 45 healthy controls. Asymmetry variables, i.e. symptomatic(S)-nonsymptomatic(NS) side diameter difference and the ratios (S/NS, log NS/S or S/S+NS) displayed higher sensitivities than variables which express the function of the symptomatic and the nonsymptomatic side pupil separately. Thirty percent of patients had abnormal S-NS values at maximal pupillary dilatation. The statistical properties of different ratio variables are discussed and it is concluded that the transformed ratio (log(NS/S], anisocoria (S-NS) and the anisocoria index (S/S+NS) may be superior to the conventional S/NS ratio.

A comparison of heat-induced forehead sweating and cutaneous temperature patterns has been carried out in 17 healthy individuals (a total of 54 measurements). Only minor asymmetries in facial sweating and temperature were observed. No significant correlation between sweating and cutaneous temperature was found. The reproducibility of the method was excellent.

The ocular sympathetic function was examined in 79 healthy volunteers (37 males and 42 females) by electronic pupillography. Pupillary diameters were first estimated under standard light conditions prior to drug application, these diameters being termed "basal values". Then, the pupils were stimulated pharmacologically by instillation of various sympathicomimetic drugs: tyramine tests were carried out in 42 individuals (24 females; 18 males), hydroxyamphetamine tests in 38 (22 females and 16 males), and phenylephrine tests in 43 individuals (23 females and 20 males). Generally, only a minor variation in the frequency of asymmetries was observed between sexes as well as between the various age groups, both when calculating the increase in pupillary diameter in millimeters, in per cent, and as the anisocoria index. In agreement with previous investigations, pupil size was found to diminish with age. The use of an age-matched control material is mandatory when comparing pupillographic recordings in patients in various categories, in the ordinary condition, as well as after topical drug administration.

In cluster headache, forehead sweating is frequently pathological and for this reason it is important to know the normal pattern. In the present work, sweating was induced by exercise and pilocarpine in 14 healthy individuals in the age group 24-50 years. A comparison was also made with patterns of heat-induced forehead sweating. No definite left-right asymmetry or medial-lateral preponderance were observed. As expected, the sweat patterns following body heating and exercise were rather similar. However, there was a significant relative increase in lateral forehead sweating with heat-induction as compared to pilocarpine-induction. In comparative intra- or inter-individual studies of forehead sweating, the method of sweat provocation may, therefore, not be indifferent.