The European Headache and Migraine Trust International Congress (EHMTIC) is a joint conference of the Migraine Trust and European Headache Federation that is held once every two years alternating with the International Headache Congress organised by the International Headache Society.

The two meetings are considered the best headache conferences and provide an opportunity for younger scientists and clinicians to present their research and network with the leading headache experts. The meeting was attended by 800 healthcare professionals from more than 50 countries and various disciplines with an interest and expertise in dealing with headache patients. A central venue at the Hilton Metropole near the Edgware Road tube station was attractive to the delegates for its proximity to some of the most famous Middle Eastern restaurants in the vicinity.  Moreover the venue had the facilities to run all activities under one roof avoiding the need to commute in unpredictable British weather.

The conference, held over four days, had teaching sessions on the first day and public awareness sessions on the last day.  The teaching courses were aimed at a general audience of general practitioners, specialist nurses and therapists involved in headache care.  There were invited lectures delivered by the leading experts, scientific presentations as platforms and posters along with a satellite symposium with academic and promotional contents. The parallel sessions were carefully planned to attract the relevant audience in each session. There were sessions dedicated to headaches in primary care, paediatric headaches and headaches in women.

Dr Tobias Kurth delivered the McDonald Critchley lecture on the epidemiology of migraine genetics and updated the conference on the recent advances on the hunt for a specific gene for migraine. Migraine has a genetic cause but so far the gene has only been identified in the rare familial hemiplegic migraine.

Dr Irene Tracey from Oxford University presented a very interesting lecture on the relevance of pain imaging studies in understanding migraine.  She discussed the  recent advances in understanding pain processing, cognitive and emotional modulation as well as the consequent pain perception using very advanced neuroimaging modalities such as a seven Tesla MRI scanner, functional MRI and PET scanning. Dr Tracey touched upon the role of various brain structures such as periaqueductal grey matter (PAG) and the rostral ventromedial medulla (RVM) in modulating the way we perceive pain! The imaging studies indicate that patient expectations of treatment can play a major role in the treatment outcome.

Dr Clifford Woolf from Harvard University gave a talk on how traditional preclinical research approaches in developing analgesics has its own pitfalls. With the creation of non human pain surrogate models, it is not able to predict how efficacious new analgesics will be in treating human pain, which in turn is responsible for the lack of discovery of new analgesics over the last twenty years. Dr Woolf is advocating a new approach in developing new pharmacological pain treatments which target the disease phenotype, with the patient being the main driver in that approach.

Professor Messlinger delivered the Migraine Trust lecture on research approaches in understanding the biology of migraine. He stressed the importance of a better understanding of pain sensitive structures of the cranium, the trigeminocervical complex along with pain-modulating brainstem structures. He also suggested that the role of neurotransmitters in migrainous pain and their utility in pain models as experimental triggers was key to future research.

Dr Rigmore Jensen gave a nice overview that summarised advances achieved in combating migraine. His starting point was the discovery of the currently used triptans and extended to recent advances in understanding the pathophysiology  of migraine, the emerging implementation of Botox and the future utilisation of magnetic stimulation in migraine management.

Dr S Ashina talked about the relationship between depression and risk of transformation to chronic migraine, for which he received the Enrico Greppi award.

There were three invited lectures by new scientists in the headache world. Dr Ashgar reported findings on the use of glyceryl trinitrate and calcitonin-gene-related peptide (CGRP) on Blood-Oxygen-Level-Dependent (BOLD) signal using functional MRI. The study showed that CGRP dilates the middle meningeal artery but not the middle cerebral artery. He concluded that sumatriptan and CGRP exercise their effect outside the blood brain barrier.  Dr Andreou presented fascinating new results studying cortical spreading depression and its ability to modulate tertiary neurons central sensitisation in the thalamus even after trigeminal ablation. These findings have great potential for the development of innovative approaches in treating migraine.

Dr Magis presented results of functional imaging in a large series of their patients with chronic cluster headache treated with occipital nerve stimulation.  Patients were followed up for five years and their results showed that although patients with cluster headache show normalisation of hyperactivation at the pain centre, the autonomic centre remains active. This accounts for the persistence of such symptoms even during pain freedom. She received the Guiseppe Nappi award.

There were interesting posters related to all aspects of headache.  The headache group in San Francisco lead by Peter Goadsby reported that changes in the functional MRI of patients commence long before the actual migraine attack in the prodrome phase.

As in every conference there were satellite symposia sponsored by the manufacturers of drugs and devices.  The symposium by eNeura that manufactures the spring Transcranial Magnetic Stimulation (TMS) device reviewed the past, present and future of neurostimulation and how the research is heading towards non-invasive and non-pharmaceutical ways of treating migraines. Although the evidence stemmed from its use in patients with aura, the real life experience has seen benefit in all forms of migraine as an abortive treatment. The symposium sponsored by Allergan had speakers talking on the post-licensing experience of using Botox in Chronic Migraine and studies looking into the cost-effectiveness of this treatment. Allergan also arranged a breakfast workshop where attendees had a chance to learn the injection technique for Botox in Chronic Migraine.  The technique was demonstrated on an MIA head.  A symposium by Linde discussed cluster headache in Europe, its economic cost, and a recent trial on which was the best oxygen mask to use and another trial on utilising a demand valve in oxygen delivery for cluster headache attack.  The symposium by Menarini focused on issues of migraine in women. Dr Anne MacGregor described menstrual related migraines as more disabling than other forms and how this could be treated with long acting triptans.

All in all, the conference was an excellent opportunity for anyone with an interest in headache to learn about the diagnosis and management of common headache disorders. There were many opportunities for them to familiarise themselves with the ongoing research in the disorder and the development of new treatments. This also provided an opportunity to meet some of the famous names in headache research and be able to ask them questions face to face!