Migraine headache is a unique disease entity which is known to manifest in both neuropathic and visceral fashions. The neurovascular theory holds that a complex series of neural and vascular events initiates migraine, primarily a neurogenic process with secondary changes in cerebral perfusion.¹ At baseline, a migraineur, who is not having any headache, has a state of neuronal hyperexcitability in the cerebral cortex, especially in the occipital cortex. This then sets off a subsequent sequence of multi-mechanistic actions throughout the full spectral manifestation, i.e., inflammation, vasodilation, nociceptors, and peripheral and central sensitization. Furthermore, migraine is often associated with psychiatric disorders including depression and anxiety. While highly selective pharmacological agents may playa crucial role in the respective etiology, neither drugs nor interventions are sufficient to hold off the symptoms as stand-alone remedies, based on the multi-faceted mechanisms. Non-pharmacological cognitive-behavioral therapy, e.g., relaxation and thermal biofeedback, has been accepted as an efficacious adjuvant for recurrent migraine.² Thus, a successful treatment strategy must consist of a comprehensive portfolio covering the full spectrum of underlying pathogeneses associated with migraine headache.

Multimodal analgesia is currently accepted as the standard strategy for acute pain service, because postoperative pain is triggered by a complex and multifactorial pathogenesis which requires a thoughtful approach using a variety of treatment modalities, to obtain an optimal outcome after surgery, reduce the amount of medications necessary to relieve pain, and minimize uncomfortable side effects.³

Into the 21^st century, cutting-edge technologies keep breaking through the domain barriers to revolutionize the modern medical practices, both in diagnosis and in treatment perspective. Genetics and molecular biology, for instance, have revealed the complex signal transduction pathway underlying almost any disease entity. As a result, target-oriented therapies are replacing the classical pharmacological modalities to become the mainstream treatment of choice in modern oncology and rheumatology. More strikingly, high-end image technologies, such as MRI and ultrasound, have changed the global clinical practice in discovering the structural and functional disorder within the organs and systems, where conventional approaches could hardly explore or observe. Literally, this is an era of objective measurement, where disease entities can be readily quantified and dissected by digital format or molecular probe.

All these scientific breakthroughs of the past decades, however, are neither helpful nor contributory in improving the overall therapeutic outcome of migraine headaches. Although earlier studies with EEG and fMRI have demonstrated the neurogenic process associated with cortical spread, secondary changes in cerebral perfusion are not readily discovered from the high tech images. Diagnosis and measurement of migraine headaches are primarily based upon reported symptoms, with respect to the time of day headaches occur, specific location, how the pain is felt, how long headaches last, changes in behavior or personality, effect of changes in position or activities, effect on sleep patterns, effect of stress in your life, and history of any head trauma. Advanced technologies, e.g., CT scans, MRI and spinal tap, remain to be the confirmative test helping to rule out other causative pathogenesis, such as tumors, infection, or blood vessel irregularities, which may cause migraine-like symptoms. Thus, migraine headaches rely heavily on even more comprehensive dissection into the essence of subjective feelings rather than the objective measurement per se.

Despite their unequivocal value in helping diagnosis, the complexities of various tools clearly consume the limited availability of clinical resources, i.e., time and labor, while the burden of tiring questionnaires confuse and irritate the patients in sufferings. In this review, Peng and Wang examined the commonly used instruments in daily practice and the research into migraine, to highlight their clinical applications and pitfalls in interpretation.⁴ With the holistic perspectives on treatment, patient-centered schemes can be derived and re-organized from the available instruments. The multi-faceted information enables the experienced clinicians to link the functional, sleep, and emotional impairment to the underlying mechanisms associated with inflammation, vasodilation, nociceptors, and peripheral and central sensitization. Consequently, as guided by the target-oriented endpoint, clinicians opted to design their multimodal approaches so as to ensure the comprehensive analgesia of migraine headache.

Ultimately, you get what you measure. The rule of “less is more” applies to daily clinical practice, when the balance between maximal information and minimal consumption is reached through logical choices.