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Migraine visual aura is heterogeneous and pleomorphic, and some of our findings run contrary to common beliefs.

The purpose of the study was to compare the impact of continuing medical education for primary care physicians in Halifax, Nova Scotia, Canada, delivered through a problem-based learning (PBL) format with that of a lecture-based format, in the clinical area of headache diagnosis and management. From January to June 1995, 38 physicians participated in three problem-based learning sessions, and 49 in a lecture-based session in the clinical area of headache. Pre- and posttest assessments of knowledge were made of each group before and immediately after the educational sessions. A second evaluation using Key Features Problems (KFP) to measure clinical reasoning was administered to both groups 3 months later. Analysis of covariance between groups on the post-test, using the pre-test result as covariate, showed significantly greater knowledge in the PBL group. Mean post-test KFP scores also were significantly higher for the PBL group. The PBL group's satisfaction with several programme dimensions was significantly higher than that of the lecture group. These results must be viewed in the context of differing amounts of exposure for the two groups. Problem-based learning in continuing medical education in the area of headache management was associated with greater knowledge acquisition and with greater improvement in clinical reasoning skills than in a lecture-based approach. Problem-based learning also was preferred by family physicians. However, the cost-benefit of this approach was questioned, since the PBL group had more exposure. Several factors limit the generalizability of this study, e.g. the impossibility of randomly composing the two experimental groups. Further research is required to determine if the results are generalizable and whether a PBL approach results in change in practice behaviour.

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Headaches occurring during commercial airplane descent with normal examinations and imaging have been rarely reported. Four cases of airplane descent headaches are described, 3 with new features. CLINICAL HISTORYCase 1.-A 22-year-old male reports headache triggered by descent to land on commercial jet airplanes. The first was 2 years previously where he had identical headaches on descent on the departure and returning flights which were both the same as the most recent. Two weeks previously, he was descending to land when he developed a sudden, shooting, bursting pain in the left temple with a 10/10 intensity at onset without associated nausea, light, or noise sensitivity. There was no ear pressure, popping, or change in hearing. The headache was a 10/10 for about 25 minutes. Upon landing, he took ibuprofen and then the headache was mild with a 5/5 intensity for another 30 minutes. In addition, from the onset of the headache, the neck was For CME, visit